More than 27 million people in the United States, over 8% of the population, have limited English proficiency (LEP). For these patients, having access to interpretation services throughout the continuum of care is essential to receiving optimal care. This is an especially crucial—and challenging—issue in otolaryngology-head and neck (ENT) surgery, where patients often struggle with speech, language, or hearing problems.
Regan W. Bergmark, MD, a sinus and endoscopic skull base surgeon in the Division of Otolaryngology-Head and Neck Surgery at Brigham and Women’s Hospital, has long been interested in health equity, healthcare access, and outcomes. She is a co-principal investigator on a project aiming to advance language-concordant care in otolaryngology-head and neck surgery throughout the Mass General Brigham system. The team is trialing a mobile app that provides patients and physicians with live video interpretation on demand.
“We’re trying to make sure all our patients can access truly equitable, high-quality care regardless of their background or language,” Dr. Bergmark says.
United Against Racism, a Mass General Brigham initiative designed to combat systemic racism in healthcare, is funding this work. The current grant focuses on disparities in care access among LEP patients and Black and Latinx patients in otolaryngology-head and neck surgery. Participating Mass General Brigham institutions include the Brigham, Massachusetts General Hospital, and Mass Eye and Ear.
Complex Referral Patterns Lead to Navigation Troubles
Ciersten A. Burks, MD, Mass General Brigham/Mass Eye and Ear chief resident, has been involved in Dr. Bergmark’s work since early in her residency training. She bemoans the significant disparities that Black, Latinx and LEP patients face in accessing care.
“There are multifactorial reasons for this, including referral patterns, insurance type and status, lack of diversity in the physician/surgeon workforce and the impact of systemic racism,” Dr. Burks says. “In head and neck cancer, this can have a negative impact on stage at time of diagnosis and subsequent morbidity and mortality.”
Dr. Bergmark agrees that complex referral patterns are a particular concern in LEP patients. “We see people referred to us by a PCP or specialist, who self-refer, who come into an emergency department for an emergency, who transfer from one hospital to another,” she says. “There are many possible steps. And in any of those pathways, LEP patients have more trouble navigating the system and are less likely to make it to our doorstep.”
In the project’s first year, Dr. Bergmark and her team worked to ensure patient instructions and selected patient-reported outcome metrics (PROMs) and other materials were available for patients in multiple languages. Then they shifted their focus to language concordance—clinical encounters where the patient and physician communicate in a shared language.
The solution being trialed among residents and surgeons is a mobile interpretation app that connects patients and physicians via video with an interpreter. Gezzer Ortega, MD, MPH, a colleague of Dr. Bergmark’s in the Brigham’s Center for Surgery and Public Health, has been a key collaborator in this work.
“In ENT, many patients have conditions that limit their hearing, speech, or communication capacity. Adding a language barrier on top of that complicates things even further,” Dr. Ortega says. “If you want to address inequities in ENT, you must be mindful of the barriers that may exist because of the conditions patients are facing as well as the access disparities inherent in any surgical subspecialty.”
Finding a Solution That Fits Into Surgeon Workflows
Dr. Bergmark stresses that while in-person interpretation is the gold standard, it isn’t always possible due to surgeons’ workflows.
“We might round very quickly on a number of patients in the morning before starting OR cases, or we might round in the middle of the day between cases and aren’t sure when we’ll need interpretation,” she says. “So, we need to have these additional encounters where we can communicate effectively with patients with LEP and vice versa. Even waiting 20 minutes for an interpreter doesn’t fit into our workflow.”
The project’s next phase, which started recently, is testing an app that allows patients to call up a video interpreter on demand from anywhere. Dr. Bergmark imagines many use cases, such as patients who are picking up a prescription from a pharmacy and need assistance understanding the instructions.
“We need to make it faster to access video or in-person interpretation—it should be instant. Anything that makes it easier for providers to deliver great care is a huge win,” Dr. Bergmark concludes. “We’re lucky to be part of a system that is investing heavily in these translation and interpretation efforts.”