Breaking Down Language Barriers in Healthcare

Working as a pediatric resident in Texas has given me the unique opportunity of serving a diverse patient population. For example, my continuity clinic has a substantial number of patients who only speak Spanish. Unfortunately, I do not speak Spanish, which is not ideal for my patients. As a doctor, I strive to provide the best medical care. So I’ve really reflected upon my experiences with my Spanish speaking population, and how to best navigate the language barrier. Since it’s not feasible to make all practicing physicians learn additional languages, I highly advocate for the next best thing, hiring in-person interpreter services.

Numerous studies have shown that language barriers negatively impact healthcare. A study in New York analyzed an urban, underserved Hispanic population.1 One group could speak English, while the other group could only speak Spanish. The study concluded that English speakers reported a higher satisfaction rate with their healthcare experiences; they were more likely to have medication side effects explained to them, which impacted their compliance. Another study analyzed racial and ethnic differences in access to healthcare.2 The study concluded that the marked disadvantage in Hispanic children’s access to care may be related to a language issue. Primary care is especially important for children because they require a plethora of immunizations and need to be monitored for developmental milestones.

At my clinic, I’ve been in experiences where the phone interpreter service unintentionally worsened the communication issues. The sub-optimal audio quality was exacerbated by the masks that we were wearing due to the COVID-19 pandemic. Sometimes when the interpreter said something, my patients would point at the phone and shake their heads, implying that the interpreter was not interpreting correctly. Other times, even with my limited Spanish knowledge, I realized that the interpreter was miscommunicating information to my patients. When my clinic hired someone to work onsite as our interpreter, the clinic ran so much smoother. The patients felt much more at ease with an in-person interpreter, and I could see them letting their guard down.

A study published by the American Journal of Public Health revealed that providing interpreter services is a financially viable way of enhancing healthcare delivery to people with limited English proficiency.3 The study showed that patients who utilized the interpreter services had significant increases in physician visits and prescription drugs, which suggests that the moderate cost of interpreter services led to the huge benefit of enhancing access to primary and preventive care. People are more inclined to seek healthcare when they understand their health condition, what treatment they need, medication side-effects, and the importance of medication compliance despite the side effects. As physicians, it’s important to break down barriers to healthcare access, and hiring in-person interpreters is one way to do so.

Brina Bui, MD

References

1. David RA, Rhee M. The impact of language as a barrier to effective health care in an underserved urban Hispanic community. The Mount Sinai Journal of Medicine, New York. 1998 Oct-Nov;65(5-6):393-397.

2. Weinick RM, Krauss NA. Racial/ethnic differences in children’s access to care. Am J Public Health. 2000;90(11):1771-1774.

3. Jacobs EA, Shepard DS, Suaya JA, et al. Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services. American Journal of Public Health. 2004;94, 866_869.

“SNAP Chat”: A brief commentary based on my personal experience with the Supplemental Nutrition Assistance Program

Introduction

For about 5 years, from 2015-2020 while I was completing medical and graduate school in San Antonio, my family which consisted of myself, my wife, and our growing family (first one, then two, then three daughters) received SNAP benefits. While I do not claim to be an expert on the subject, I believe my experience gave me a unique perspective on aspects of SNAP that I had not previously considered thoroughly. After first briefly providing a generalized overview of the program, I hope to touch on a few perceived lingering limitations: 1) barriers to household participation, 2) barriers to ensuring proper nutrition, and 3) barriers to self-sufficiency. These limitations should be considered by pediatricians as they encounter patients and families who have food insecurity, so advice and resources can be helpful to and suitable for the families. 

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Guiding patients who look up medical questions online

As pediatricians, we can guide patients and their families to learn how to look up medical questions online properly. Why is it important for people to learn how to do this? There are multiple reasons:

1. We are likely to instantly get a practically infinite number of answers to any question we pose to a search engine. It is not the quantity of answers that is lacking but often the quality. The ‘signal-to-noise’ ratio decreases as we get greater and faster access to more detailed information about the world (1).

2. Our minds are not adapted to handling such large amounts of data especially when we are emotionally invested. Our brains are apt to make quick, safe, somewhat-right judgements based on limited information (2), e.g., deciding if there is a lion in the nearby rustling bushes at night.

3. Few people get advice on how to find and interpret relevant information online. Although, most of it is common sense, patients and families may be emotional and vulnerable to misinformation. Facts obvious to clinicians may not be so to non-medical people and may go undiscussed.

4. The solution is not to ask people to refrain from ‘googling’. Virtually everyone will look up something online: a weird symptom, an unfamiliar disease given as the diagnosis to a close relative, or the side effects of a medication.

5. The internet will always be a source of both true and false information. Our knowledge is fallible, and science needs alternative points of view to move forward (3).

6. In medical ethics we accept that the principle of autonomy supersedes beneficence. This means that we believe that to truly help patients and families is to empower them to be able to make sound medical decisions, not to make the decisions for them.

Recommendations for discussing potential sources of confusion:

  • The problem of anecdotal “evidence”: e.g., “So-and-so tried this alternative treatment for her disease, and it worked for her so it might work for me”. An example can illustrate the difference between anecdotal and scientific evidence to patients. In a randomized controlled trial, a large group of patients is given the novel treatment A and a control group that is similar is given placebo or the standard treatment B. Then, data is collected from both groups and analysed using statistics to find a significant difference. Only then, we can say treatment A works or does not work. This should demonstrate why it is so difficult to draw any conclusions from anecdotes. Even if we assume the anecdote of someone’s success with an alternative treatment was not falsified, many factors could distinguish them from another patient, none of which can be controlled for. Even if all other factors were the same, any positive or negative effect seen from the alternative treatment will likely be due to random chance.
  • About social media posts: Remind patients and families that people do not have any obligation to tell the truth on social media, may have different motivations than expected, or may be unwittingly misleading by leaving out pertinent facts. Even if the social media post is citing seemingly scientific studies, try to verify that a) the studies are real, b) the studies are coming from a peer-reviewed scientific journal, and c) the post is not misrepresenting the study or misinterpreting its conclusions.
  • Why searching a disease could be better than a symptom:  usually a constellation of symptoms and physical exam findings make clinicians suspect one disease or another. A symptom by itself can be remarkably non-specific and lead to excessive worry or delay in seeking help. It’s probably a good idea to suggest sticking to reputable medical websites of institutions such as the American Cancer Society or the CDC for basic information.
  • The distinction between scientific articles published on medical journals and news articles or articles on science blogs: a) Scientific articles are peer-reviewed, b) data is gathered, analyzed, and interpreted by a professional who knows the context of previous studies and standards of practice, and c) any potential conflict of interest must be declared eliminating a potential source of bias. None of these can be guaranteed for non-scientific articles.
  • Documentaries, or videos online as a source: Even if they seem to have a high production cost, these usually conflate anecdotal evidence with real scientific evidence, embellish facts for dramatic effect, and do not have to meet any scientific standards.

Today’s families are surrounded by differing sources of knowledge. Thus, part of the doctor-patient relationship should more than ever be helping families sift through the information and make the right decisions for themselves and their children.

Can Ozlu, MD

References:

  1. Taleb NN. Fooled by Randomness. New York: Random House; 2016.
  2. Kahneman D. Thinking, Fast and Slow. Penguin Books; 2012.
  3. Popper KR. The Open Society and Its Enemies. Princeton, NJ: Princeton University Press; 2011.

Creating a Family Media Plan

In these times of social distancing, I have found myself spending an increased amount of time on media. This includes social media, news websites, streaming platforms, online shopping; I am guilty of all of them. From my conversations with others and in further research, I have learned I am not alone in this. Many of my family, friends, and patients all endorse a similar increase. Between March and June of 2020, Lurie Children’s in Chicago polled 2,909 American parents of teenagers, and 63% reported their teenager was using social media more. Technology and media do have benefits and have especially helped in these times by allowing us to stay connected with loved ones, continue education, and even buy groceries from home. But they can also have negative consequences when not used in a responsible manner. I encourage all pediatricians to address media use with their patients and families. One way this can be done is by introducing the idea of a family media plan.  

In today’s era of COVID-19, virtual media is one of the easiest ways to stay connected with others. However, just because it is convenient does not mean it is benign. Facebook is still the most widely used social media website. A study from France used experience-sampling to see that rather than enhancing well-being, use of Facebook had the opposite result. The study indicated that Facebook use leads to decline in the two areas defined as cognitive and subjective well-being.  Cognitive wellbeing was how satisfied people are with their lives, and subjective well-being was how people feel moment to moment. In contrast to the use of Facebook, direct social interaction showed no change in cognitive well-being and an increase in subjective well-being.  

What about the effects of other types of media? For example, children watching television? Research shows higher media use in young children is associated with higher BMI, decreased sleep, and cognitive, language, and social/emotional delays. As far as delays, most of these are thought to be due to a decrease in a child’s interactions with their parent/caregiver. Watching television should not take the place of a child interacting with real people in their real environment, replace exercise, or decrease the amount of sleep a child gets.  

What does responsible media use look like in my own life, and how can I counsel my patients and their families? Not all use of media is bad, but it should be used judiciously. In looking for the answer to this question, I found the website www.healthychildren.org, which has information dedicated to creating a family media plan. It allows a family to create a comprehensive plan, which can be individualized for every member. It addresses screen free zones and times, device curfews, media manners and safety, healthy sleep and exercise, and more. You can find the information at https://www.healthychildren.org/English/media/Pages/default.aspx  

As a reference when creating your family media plan, the American Academy of Pediatrics recommends: 

  • For children younger than 18 months, avoid use of screen media other than video-chatting. Parents of children 18 to 24 months of age who want to introduce digital media should choose high-quality programming, and watch it with their children to help them understand what they’re seeing. 
  • For children ages 2 to 5 years, limit screen use to 1 hour per day of high-quality programs. Parents should co-view media with children to help them understand what they are seeing and apply it to the world around them. 
  • For children ages 6 and older, place consistent limits on the time spent using media, and the types of media, and make sure media does not take the place of adequate sleep, physical activity and other behaviors essential to health. 
  • Designate media-free times together, such as dinner or driving, as well as media-free locations at home, such as bedrooms. 
  • Have ongoing communication about online citizenship and safety, including treating others with respect online and offline. 

While geared towards children and adolescents, I plan to make a media use plan for myself – and I encourage other adults to do so as well! 

Jenny Riepma, MD 

References: 

Cespedes EM, Gillman MW, Kleinman K, Rifas-Shiman SL, Redline S, Taveras EM. Television viewing, bedroom television, and sleep duration from infancy to mid-childhood. Pediatrics. 2014;133(5). Available at: www.pediatrics.org/cgi/content/full/133/5/e1163pmid:24733878 

Chiong C, Shuler C; The Joan Ganz Cooney Center at Sesame Workshop. Learning: Is there an app for that? Investigations of young children’s usage of learning with mobile devices and apps. Available at: http://dmlcentral.net/wp-content/uploads/files/learningapps_final_110410.pdf 

Cox R, Skouteris H, Rutherford L, Fuller-Tyszkiewicz M, Dell’ Aquila D, Hardy LL. Television viewing, television content, food intake, physical activity and body mass index: a cross-sectional study of preschool children aged 2-6 years. Health Promot J Austr. 2012;23(1):58–62pmid:22730942 

https://pediatrics.aappublications.org/content/138/5/e20162591

https://www.luriechildrens.org/en/blog/social-media-parenting-statistics/

Kross E, Verduyn P, Demiralp E, et al. Facebook use predicts declines in subjective well-being in young adults. PLoS One. 2013;8(8):e69841pmid:23967061 

The Importance of Masking in Schools

Bastioned by the AAP’s statement1 in support of school reopenings amidst the ongoing COVID-19 pandemic, school governing bodies everywhere have established a spectrum of different masking requirements for students. Some may argue that masking could be disruptive to learning and development, particularly in young children. However, the caveat in the AAP’s statement must not be forgotten: that the school reopenings are to be driven by science and safety. Arrangements for social distancing at school are frequently changing, with some schools having greater capacity than others to space out students, and some school districts electing to continue the school year entirely online. Parents and guardians are often constrained by work or other life circumstances, including lack of financial or technological resources, giving them little choice but to send their children back to in-person education. Consistent masking practices for as many children as possible at school will greatly help to mitigate the associated risk of students and staff contracting and spreading COVID-19. Pediatricians are uniquely poised to advocate for this low-cost, minimally invasive intervention that may save countless lives of all ages. 

Without clear scientific guidance indicating that children do not contribute significantly to the spread of the pandemic, we are left to answer the question of how to proceed this academic year.

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#MaskUp Texas!

When Governor Abbott opened up Texas ahead of a downward trajectory in COVID-19 cases, the expectation was that social distancing and masking would still take place. While walking around the neighborhood, I was surprised to see unmasked diners at restaurants. There were couples and families, but also groups that did not seem to live together. As the weeks went on and restaurants were allowed to increase their activity, I saw indoor and outdoor tables with patrons back to back and yet masks were not donned. I wondered, when would we see the effects? 

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Literacy in the Time of Coronavirus

Texas is returning to normalcy as restrictions are being eased from the COVID-19 pandemic. Children are still out of school and it remains to be seen when they will return to the classroom environment. The combination of idle time, travel restrictions, and social distancing practices present a significant challenge to parents with restless children at home – as well as an excellent opportunity to promote reading. Pediatricians should use each well-child visit right now to encourage parents to take time to read with their children.

The Council on Early Childhood found approximately two-thirds of children in the United States fail to develop reading proficiency by third grade.1 Reading proficiency by third grade is an important predictor of high school graduation rates, as those who cannot read by that mark are four times more likely to later drop out of high school.1-2 Early reading deficiencies can lead to a lifetime of economic consequences. The Program for International Assessment of Adult Competencies (PIAAC), in a 2016 survey, suggested roughly 1 in 5 U.S. adults do not have basic literary proficiency.3 Low levels of adult literacy and educational level are associated with less economic opportunity, poor health outcomes, and social dependency.1,4

The promotion of reading skills can start in infancy. Parents can read aloud to infants to encourage language development and model reading behavior.1 As infants age, they begin to mimic their parents by turning the pages of books. With picture books toddlers can make inferences from the images before they can read the words on the page. Gradually and with training they may begin to recognize letters and eventually words. Ideally, pediatricians would like our patients to be familiar with the alphabet and recognize their name prior to starting kindergarten. For older children and teenagers, quarantine can be an opportunity to expand their literary horizons. By reading popular novels, classic literature, or books from high school reading lists, students can improve their literacy.

Many resources are available to help parents promote reading. Reach Out and Read Texas has a partnership with many pediatric clinics to provide children with a book at each visit from 6 months to 5 years; their website (see link below) also includes expected reading milestones by age. The Dallas Public Library has Tumble books available for children grades K-12 (see link below) online and additional books are available with a library card (free with proof of residence). Google Play Books has free children’s books available online which are playable on iOS devices.

Donovan Berens, MD

Works Referenced:

  1. High PC, Klass P, Council on Early Childhood. Literacy Promotion: An Essential Component of Primary Care Pediatric Practice. Pediatrics. 2014 August; vol 134 (2): 404-409
  2. Hernandez D. Double Jeopardy: How Third-Grade Reading Skills and Poverty Influence High School Graduation. Annie E. Casey Foundation. 2011 April. https://files.eric.ed.gov/fulltext/ED518818.pdf Date accessed 5/01/2020
  3. Mamedova S, Pawlowski E. Adult Literacy in the United States. National Center for Education Statistics Data Point, U.S. Department of Education. 2019 July. https://nces.ed.gov/pubs2019/2019179.pdf. Date accessed: 5/02/2020
  4. Torpey E. Education pays. Career Outlook, U.S. Bureau of Labor Statistics. 2019 February. https://www.bls.gov/careeroutlook/2019/data-on-display/education_pays.htm?view_full. Date accessed 5/02/2020.

Additional Resources:

https://reachoutandreadtexas.org/index.aspx

https://dallaslibrary2.org/services/ebooks/

Children’s Hospitals Need More COVID-19 Emergency Relief Funding

Since the start of the COVID-19 pandemic, the financial losses of businesses and employees in the service, retail, and entertainment industries have been the subject of a large amount of media attention. What many Americans would not expect is that health systems are also under major financial strain during this difficult time.  Pediatricians can act now by writing their U.S. Representative or Senator to express the need for additional emergency funding for children’s health systems.

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Two to Tango: Shared Decision Making

Often patients or their parents can place an expectation on our shoulders to always have a plan and answers as their physician. The shaking truth of the medical field is that this is not always possible. While the expectation is seen as a privilege by most physicians, it can also lead to significant stress and pressure. When asked specific questions that are either unanswerable or unknown at that time, a physician may find it difficult. Shared decision making is fundamental for patient care as an effective tool for a physician to use when addressing such situations with patients and their parents.

The idea of shared decision making is more recent in the field, compared to the centuries of the practice of medicine (Veatch). It is a hallmark in patient-centered care because it relies heavily on patient and/or parental input into treatment decisions. Glyn Ewlyn, et al. described a practical way to implement shared decision making using:

  • Choices: making sure that patients/parents know different, reasonable options are available to them,
  • Options: providing detailed information about all options, and
  • Decision talk: supporting and allowing for time for the patients/parents to deliberate over the available options.

While shared decision making is an important part of patient care, its use can be limited in some situations, such as in emergencies that require immediate action or conditions that require extensive use of medical knowledge to make a decision. Other limitations to shared decision making include inadequate health literacy and cultural differences in autonomy (Glyn Ewlyn et al). Even in these situations, using shared decision making as much as possible at the patient/parent’s level of understanding can help. It can be employed as a tool to help move forward in difficult situations, or even to create an open dialogue and invite parents to share their input. 

Even in pediatrics, we can involve our patients in shared decision making to empower them to actively participate in their own health. One small example includes asking them the form of medication they like (e.g.pill, liquid, or chewable) (Furman). Although we are not asking them what treatment plan they want, offering even a small choice can help empower them in their own healthcare. 

While shared decision making can be used in a positive way to forge a bond between parents and pediatricians, a one-sided relationship, whether on the parent or physician side, can be detrimental to this balance. With the advent of the internet, parents have numerous different resources to use as they deliberate their options. This should be supported and encouraged within reasonable limits by pediatricians. The balance lies within the decision talk portion of shared decision making. Pediatricians should listen to parent’s wishes and informed decisions, and parents should work with the pediatricians and trust them to make decisions for their child’s well-being. With unbalanced power on either side, friction and erosion of patients’ care can occur.

Many questions still exist as to how to best integrate and implement shared decision making from both the parent’s and the pediatrician’s role in a child’s medical care. By implementing these three steps into each patient encounter, both with a patient and their parents, pediatricians can create an optimal balance in unknown or difficult situations. 

Chelsea Burroughs, M.D.

References:

Elwyn, Glyn et al. “Shared decision making: a model for clinical practice.” Journal of general internal medicine vol. 27,10 (2012): 1361-7. doi:10.1007/s11606-012-2077-6

Furman, Lydia. “Shared Decision Making – Harnessing Trainee Enthusiasm.” American Academy of Pediatrics (2017). 

Veatch, Robert. “Models for Ethical Medicine in a Revolutionary Age.” The Hastings Center Report vol. 2, 3 (1972): pp 5-7. 

Barriers to successful HPV vaccination in US adolescents

Human papillomavirus (HPV) is the most common sexually transmitted disease in the United States with a peak prevalence in adolescents and young adults. It is a viral infection that can persist in the body and lead to a significant risk of developing various types of cancer later in life. HPV infection is preventable thanks to the advent of vaccination. The current 9-valent HPV vaccine is proven to be safe, effective and successfully prevents morbidity and mortality associated with HPV-related diseases. Pediatricians, in particular, play a key role as providers of vaccination but also need to become leaders in HPV-vaccination education for children, adolescents and their parents.
Current guidelines from the Centers for Disease Control and Prevention (CDC) US Advisory Committee on Immunization Practices (UCIP) and the American Academy of Pediatrics (AAP) recommend initiating the 9-valent vaccine with 2-dose schedule at ages 11-12 (although can be started as early as age 9) and 3-dose schedule for those starting at ages 13-26. [2]
However, the HPV vaccination rate in the U.S. is still very low, particularly among adolescents, with less than two-thirds of adolescents ages 13-17 receiving at least one dose of the HPV vaccine. In Texas, low vaccination rates are even more prevalent in rural areas and border towns with higher Hispanic/Latino populations. Thus, Hispanic women in areas such as the Rio Grande Valley are at significantly higher risks for cervical cancer incidence and mortality than Hispanic women generally in the U.S. [1-3]
Under current Texas health law, adolescents can obtain health information on safe sexual practices, self-request pregnancy tests, contraception and STI tests confidentially with medical providers. HPV vaccination, however, is under immunization/vaccine law and thus requires parental consent for a teen to be vaccinated. Studies have shown that there is misinformation in the community regarding HPV vaccination, and that leads to parents declining HPV vaccination for their children. That in in turn leads to lower vaccination rates. Some barriers to vaccination cited include concerns about vaccine’s effect on sexual behavior, low perceived risk of HPV infection, social influence, irregular preventive care and concern for out-of-pocket costs. Interestingly, parents also cited healthcare professionals’ recommendations as one of the most important factors in their decision to vaccinate. [1]
Misinformation appears to be the key driving force behind suboptimal vaccination rates. This is in line with studies that have shown that parent/adolescent education and vaccination availability are key to addressing the issue. As an example, a single onsite school-based active vaccination program coupled with physician-led education on HPV and HPV vaccines for parents/guardians, school nurses and pediatric/family providers in a rural community in south Texas led to almost double HPV initiation and completion rates. [1,3]
Parents can find it complicated to navigate around all the misinformation around vaccinations, especially in a climate of a generalized sense of distrust geared toward the medical/pharmacological enterprise. Pediatricians and family medicine providers should clearly inform patients and their parents about the distinct benefits and safety regarding HPV vaccination, and the drastic, positive impact the vaccine provides in preventing HPV-associated cancer.
Cost should be less of a barrier, because the Patient Protection and Affordable Care Act requires insurance companies to cover ACIP-recommended vaccines without copays, and federal programs provide vaccines to Medicaid eligible children without cost. Finally, pediatricians should also establish strategic partnerships with schools and local health providers to develop active education programs and on-site vaccination programs. These steps can improve successful HPV vaccination rates and reduce risks for HPV-associated cancers.
1. Holman DM, Benard V, Roland KB, Watson M, Liddon N, Stokley S. Barriers to Human Papillomavirus Vaccination Among US Adolescents: A Systematic Review of the Literature. JAMA Pediatr. 2014 Jan; 168(1): 76–82.
2. Yang DY, Bracken K. Update on the new 9-valent vaccine for human papillomavirus prevention. Can Fam Physician. 2016 May; 62(5): 399–402.
3. Kaul S, Do TQN, Hsu E, Schmeler KM, Montealegre JR, Rodriguez AM. School-based human papillomavirus vaccination program for increasing vaccine uptake in an underserved area in Texas. Papillomavirus Res. 2019 Dec;8:100189.
B. CICERO WILLIS-PINEDA M.D.