GOOD AFTERNOON.
I'M THE DIRECTOR OF THE NATIONAL
INSTITUTE ON MINORITY HEALTH AND
HEALTH DISPARITIES.
I WANT TO THANK YOU FOR JOINING
US TODAY FOR THE NIMHD DIRECTOR
SEMINAR SERIES.
AS YOU MAY KNOW WE ARE IN
HISPANIC HERITAGE MONTH WHICH IS
CELEBRATED FROM SEPTEMBER 15 TO
OCTOBER 15 EVERY YEAR.
THE 2023 THEME IS WE ARE ALL WE
ARE ONE.
THIS THEME CAPTURES THE
UNWAIVERRING STRENGTH,
RESILIENCE AND GRIT DEEPLY
INGRAINED WITHIN THE LATINO
COMMUNITIES.
IN HONOR OF HISPANIC HERITAGE
MONTH I INVITED ALICIA FERNANDEZ
TO BE OUR SPEAKER TODAY.
HER PRESENTATION IS ENTITLED HOW
LANGUAGE BARRIERS CONTRIBUTE TO
HEALTHCARE DISPARITIES.
A FEW WORDS ABOUT ALICIA.
SHE'S A GRADUATE OF YALE
UNIVERSITY AND THE ALBERT
EINSTEIN COLLEGE OF MEDICINE.
SHE'S A NATIVE OF ARGENTINA AND
IMMIGRATED TO THE U.S. AT THE
TIME OF THE DICTATORSHIP.
I MET HER WHEN SHE WAS A FIRST
YEAR MEDICAL RESIDENT.
AFTER A YEAR AS CHIEF RESIDENT
AND FELLOWSHIP, SHE JOINED THE
FACULTY AT SAN FRANCISCO GENERAL
AND HAS BEEN INVOLVED IN
MULTIPLE RESEARCH, EDUCATIONAL
AND CLINICAL PROGRAMS AT UC F.
ALICIA IS A PROFESSOR OF
MEDICINE PRACTICING AT SAN
FRANCISCO GENERAL HOSPITAL AND
ASSOCIATE OF POPULATION HEALTH
AND HEALTHS EQUITY FOR THE
SCHOOL OF MEDICINE.
SHE'S ALSO HAD HEALTH RESOURCES
AND SERVICE ADMINISTRATION
CENTERED OF EXCELLENCE ON LATINO
HEALTH AT UCS F.
DR. FERNANDEZ DIRECTS THE
IMMIGRANT HEALTH PROGRAM AT THE
USCF PROGRAM.
HER RESEARCH EXPERTISE INCLUDES
LANGUAGE AND LITERACY BARRIERS
WHICH WE'LL HEAR ABOUT.
HEALTHCARE EQUITY IN CHRONIC SA
DOZES AND BIASES IN MEDICINE
JUST TO NAME A FEW.
SHE'S PUBLISHED OVER 160 PEER
REVIEW PUBLICATIONS.
SHE'S RECEIVED A NUMBER OF
TEACHING AWARDS RECOGNITION FROM
THE SAN FRANCISCO PUBLIC HEALTH
DEPARTMENT AND MOST RECENTLY A
DISTINGUISHED CITIZEN AWARD FROM
THE COMMON WEALTH CLUB IN SAN
FRANCISCO.
ALL OF THIS FOR HER WORK TO
ADDRESS ISSUES AROUND HEALTHS
DISPARITIES, WORK FORCE
DIVERSITY AND SOCIAL JUSTICE.
ALICIA HAS SERVED IN A NUMBER OF
PANELS ON A NATIONAL LEVEL BUT
MOST IMPORTANTLY SHE'S BEEN A
MEMBER OF THE BOARD OF GOVERNORS
FOR THE PATIENT CENTERED
OUTCOMES VERGE INSTITUTE FOR A
NUMBER OF YEARS.
SINCE 2020 SHE'S ALSO BEEN ON
THE BOARD OF DIRECTORS OF THE
AMERICAN BOARD OF INTERNAL
MEDICINE WHICH GOVERNS THE
CLINICAL TRAINING OF INTERNAL
MEDICINE RESIDENCY.
PLEASE JOIN ME IN THIS VIRTUAL
WELCOME TO OUR HISPANIC HERITAGE
MONTH SPEAKER LISA
SAPINSLEYLESS.
>> DR. FERNANDEZ: THANK YOU SO
MUCH.
I'M DELIGHTED TO BE HERE.
I'LL SHARE MY SLIDES.
IT SHOULD BE COMING UP NOW.
THANK YOU SO VERY MUCH FOR
HAVING ME HERE.
I'M TRULY HONORED TO BE WITH YOU
NIH.
FUNDING HAS BEEN CRUCIAL TO MY
WORK AND CRUCIAL TO ADVANCING
SCIENCE TREMENDOUSLY.
I'M PARTICULARLY GLAD TO BE ABLE
TO ADDRESS THE STAFF AND
SCIENTISTS WHO WORK AT NIH AND
SPECIFICALLY AT NIMHD.
WHAT I THOUGHT I WOULD COVER
TODAY IS TALK A LITTLE BIT ABOUT
THE CONTEXT OF LANGUAGE BARRIERS
AND THEN TALK ABOUT WHAT WE KNOW
ABOUT LANGUAGE BARRIERS AND
PATIENT OUTCOMES AND LANGUAGE
BARRIERS IN CLINICAL OUTCOMES
AND I MIGHT SHARE WITH YOU A
VERY FEW THOUGHTS ON HOW WE CAN
MOVE FORWARD IN THIS WORK.
MY HOPE IS TO LEAVE PLENTY OF
TIME FOR QUESTIONS AND
DISCUSSION AS THAT NOURISHES ME
AND I THINK NOURISHES ALL OF US
IN OUR SCIENCE.
I DID WANT TO TAKE A MOMENT TO
TALK ABOUT MY VERY LONG JOURNEY
HERE.
I THINK THAT ACTUALLY MOST OF IT
WAS COVERED.
BUT WHAT I WANTED TO HIGHLIGHT
WAS HOW IMPORTANT AND CRUCIAL AN
INTERNAL WAS TO MY CAREER.
WHAT I'VE WRITTEN HERE IS TRUE.
WITHOUT HAVING HAD THE
INCREDIBLE FORTUNE OF CROSSING
PATHS WITH HIM EARLY ON IN MY
CAREER I WOULD NEVER HAVE BECOME
AN ACADEMIC AND NEVER GONE INTO
RESEARCH.
HE'S BEEN A CONSTANT SOURCE OF
GUIDANCE, OF EMOTIONAL SUPPORT
AND QUITE FRANKLY OF INSPIRATION
IN ALL OF HIS WORK.
AND THAT MAKES ME EVEN MORE
HONORED TO BE HERE.
AND ALSO BEFORE I START, I WANT
TO SAY THAT I DO SEE PATIENTS AT
SAN FRANCISCO GENERAL HOSPITAL.
AND WE ARE THE ONLY PUBLIC
HOSPITAL IN A HIGHLY DIVERSE
CITY.
WE HAVE OVER 40 LANGUAGES SPOKEN
PER MONTH, OVER 120 PER YEAR.
WE HAVE AWARD WINNING
PROFESSIONAL INTERPRETERS AS
WELL AS RELYING ON COMMERCIAL
SERVICES.
AND EVEN THOUGH I HAVE A VERY
SMALL PANEL OF SOMEONE MAINLY
FOCUSED ON RESEARCH N. MY
PERSONAL PANEL THERE ARE PEOPLE
WHO SPEAK ALL SORTS OF LANGUAGES
INCLUDING OF COURSE MANDARIN,
VOTE NA MEESE AS WELL AS OTHERS.
AND I BRING THIS UP BECAUSE IN
MY TALK I'M GOING TO BE TALKING
A LOT ABOUT SPANISH SPEAKERS
BECAUSE THAT'S WHERE I FOCUS MY
RESEARCH.
IT CAN BE TOO EASY TO THINK WELL
SHE HAS A PRIVILEGED POSITION
VISA SEE LANGUAGE BARRIERS THAT
CAN SHAPE THE WAY PEOPLE LISTEN.
I ENCOUNTER LANGUAGE BARRIERS
EVERY DAY THAT I DO CLINICAL
WORK.
BECAUSE I DON'T ACTUALLY SPEAK
ANY OF THESE OTHER LANGUAGES
OTHER THAN SPANISH.
SO WITH THAT CONTEXT, LET ME GET
STARTED.
AS YOU MAY KNOW, THERE IS
DIVERSITY THROUGHOUT THE UNITED
STATES.
IT'S NOT JUST IN THE TRADITIONAL
IMMIGRANT PORTALS.
AND HERE THESE DARK BARS
REPRESENT AREAS STATES WHERE
OVER 28 PERCENT OF THE
POPULATION SPEAKS A LANGUAGE
OTHER THAN ENGLISH AT HOME.
BUT EVEN THE VERY LIGHTEST BARS
REPRESENTS STATE WHICH IS HAVE A
LITTLE UNDER 7 PERCENT OF PEOPLE
SPEAK SPANISH.
AS YOU CAN SEE THERE ARE MANIES
PLACES WHERE THE PROPORTION OF
PEOPLE WHO SPEAK SPANISH IS
BETWEEN 10 AND 30 PERCENT.
ANOTHER WAY OF LOOKING AT THE
SAME DATA IS WHILE THE
PROPORTION OF PEOPLE WHO SPEAK
ENGLISH IS MORE OR LESS REMAIN
THE SAME, THE NUMBER OF PEOPLE
WHO SPEAK SPANISH -- SORRY, THE
NUMBER OF PEOPLE WHO SPEAK A
LANGUAGE OTHER THAN ENGLISH AT
HOME HAS GROWN BOTH AS A
PERCENTAGE OF THE POPULATION BUT
ALSO AS -- BUT ALSO IN ABSOLUTE
NUMBERS.
I THINK MOST PEOPLE REALIZE
SPANISH IS THE DOMINANT
NON-ENGLISH LANGUAGE.
I WANT TO EMPHASIZE HOW
EXTRAORDINARILY DOMINANT IT IS.
61 PERCENT OF THE LANGUAGE OTHER
THAN ENGLISH AT HOME SPEAK
SPANISH.
AND THE NEXT MOST COMMON
LANGUAGE IS WHAT THE CENSUS
QUALIFIES AS CHINESE WHICH
GROUPS LANGUAGES AS DIVERSE AT
CAN'T NIECE ETC.
ALL THE OTHER LANGUAGES FALL
UNDER 2 PERCENT OR 1 PERCENT.
SO 68 MILLION PEOPLE SPEAK A
LANGUAGE OTHER THAN ENGLISH AT
HOME, MORE THAN HALF ARE SPANISH
SPEAKERS.
SO ANOTHER WAY OF THINKING ABOUT
THIS IS THAT IS TO MENTION THE
IMPORTANCE OF LINEAGESICALLY
ISOLATED HOUSEHOLD.
HOUSEHOLDS WHERE NO ADULT SPEAKS
ENGLISH.
AMONG SPANISH SPEAKERS, AROUND
22 PERCENT OF HOUSEHOLD ARE W
LIMITED ENGLISH SPEAKERS WHERE
PEOPLE SPEAK LESS THAN VERY
WELL.
MORE THAN 22 PERCENT ARE
ISOLATED.
I DON'T WANT TO BEAT AN OBVIOUS
ONE.
WHAT IS IMPORTANT TO SAY IS
13 MILLION PEOPLE IN THE U.S.
REPORT SPEAKING ENGLISH NOT AT
ALL OR NOT WELL.
THEY TRULY HAVE LIMITED ENGLISH
PROFICIENCY.
13 MILLION PEOPLE IS ABOUT
4 PERCENT OF THE POPULATION.
AND THAT IS EQUIVALENT TO ALL
PATIENTS WITH SCHIZOPHRENIA,
RHEUMATOID ARTHRITIS, HEP-C AND
END STAGE RENAL DISEASE GROUPED
TOGETHER.
I USE THIS TO EXPLAIN HOW
IMPORTANT IT IS TO THINK ABOUT
LANGUAGE ACCESS.
THAT THEY ARE TRULY MILLIONS OF
PEOPLE INVOLVED WHO FACE PROBLEM
WITH LANGUAGE.
WITH THAT LET ME TURN TO ONE OF
THE FIRST PROBLEMS PEOPLE FACE
AND THAT IS UNDERUSE OF
INTERPRETERS.
AS YOU KNOW PROFESSIONAL
INTERPRETERS ARE KNOWN TO
IMPROVE PATIENT AND CLINICAL
OUTCOMES, PATIENT REPORTED
CLINICAL OUTCOMES.
THERE ARE DECADES OF VERGE ON
THIS.
THERE ARE MANY SYSTEMATIC
REVIEWS THAT SHOW THIS.
HERE THE COMPARISON IS ADD H, E
OC INTERPRET TORNADOES.
FAMILY MEMBERS OR STAFF ASKED TO
INTERPRET AND NOT TRAINED AS
INTERPRETERS.
IT IS ALSO WELL KNOWN THAT WHILE
THIS IS MANDATED BY FEDERAL
STATUTE, WHAT PEOPLE TURNOVER AS
AN UNFUNDED MANDATE.
MEANING HEALTH SYSTEMS THAT
RECEIVE FEDERAL FUNDS WHICH
MEANS ALL HOSPITALS MUST PROVIDE
INTERPRETATION FOR GROUPS OF
PATIENTS THAT MEET A PARTICULAR
THRESHOLD BUT ARE NOT -- HAVE NO
MECHANISM BY WHICH TO FUND THOSE
SERVICES.
WHICH IS WHY THOSE SERVICES ARE
USUALLY UNDERFUNDED.
AND USUALLY AND VERY OFTEN NOT
EMPLOYED.
THIS IS DESPITE TECHNOLOGICAL
ADVANCES INCLUDING VIDEO
INTERPRETATION WHICH MAKES
INTERPRETATION MORE EFFICIENT TO
DEPLOY AS WELL AS MORE
EFFECTIVE.
IN FACT, IN ONE STUDY ONLY
70 PERCENT OF HOSPITALS ACTUALLY
OFFERED LANGUAGE SERVICES.
AND STUDIES OF USE DOCUMENT VERY
LOW RATES, BE IT IN PATIENTS
UNDERGOING INPATIENT SERVICE,
INFORMED CONSENT FOR SURGERIES
AND PROCEDURES, BE IT IN OFFICE
SPACE PHYSICIANS WHERE
29 PERCENT IN A RECENT STUDY
29 PERCENT OF OFFICE BASED MDS
REPORTED USING PROFESSIONAL
INTERPRETERS OFTEN.
BUT 40 PERCENT REPORTING USING
THEM NEVER DESPITE TAKING CARE
OF PATIENTS WITH LIMITED ENGLISH
PROFICIENCY.
A RESEARCH IMPERATIVE IS TO
ACTUALLY BE ABLE TO TRACK
UNDERUSE OF INTERPRETERS USING
NATIONAL DATA.
WE HAVE NO METHODS TO DO THAT
CURRENTLY.
SO CURRENTLY HAVE REALLY NO
METHODS TO TRACK ON A NATIONAL
LEVEL HOW MUCH IMPROVEMENT THERE
IS OR NOT IN USE OF LANGUAGE
ACCESS SERVICE TO PROFESSIONAL
INTERPRETERS.
IN A RECENT STUDY IN OUR
HOSPITAL, WE FOUND THAT OUR
RESIDENTS REPORTED DOING A MUCH
BETTER JOB IN USING INTERPRETERS
WHEN THEY HAVE TO GET
PROFESSIONAL CONSENT HERE IN
BLUE.
BUT IN DAILY ROUNDS FOR EXAMPLE
WITH PATIENTS IN THE HOSPITAL,
45 PERCENT REPORTED GETTING BY
MEANING NOT USING PROFESSIONAL
INTERPRETERS AND INSTEAD RELYING
ON GESTURES OR ON ONE WORD OF
SPANISH OR VIET.
I ALSO WANT TO POINT OUT THIS IS
A ACADEMIC MEDICAL CENTER WHERE
THERE HAS BEEN A LOT NOT NONOUR
HOSPITAL BUT IN ALL HOSPITALS
THERE HAS BEEN A LOT OF
ATTENTION PAID TO HOW IMPORTANT
IT IS TO USE PROFESSIONAL
INTERPRETERS.
THERE IS A LONG WAY TO GO
PARTICULARLY IN INSTRUCTIONS
WHICH IS THE CRUCIAL STEP TO
ENSURING THAT PATIENTS GET GOOD
CARE AS THEY LEAVE THE HOSPITAL.
WHY DO WE UNDER USE?
I TALKED ABOUT ONE OF THE MOST
IMPORTANT PARTS WHICH HAS TO DO
WITH NOT VALUING AND NOT FUNDING
INTERPRETER SERVICE FULLY
ENOUGH.
AND SUBSEQUENTLY THERE IS
USUALLY A WAIT AND A HASSLE
FACTOR.
WHEN CLINICIANS ARE INTERVIEWED
ABOUT WHY THEY DON'T USE
INTERPRETERS, THEY SAY WE USE
THEM IN IMPORTANT SITUATIONS.
I WOULDN'T START CHEMO THERAPY
WITHOUT USING AN INTERPRETER.
I WOULDN'T MAKE A DECISION BASED
ON ADVANCED DIRECTIVES WITHOUT
USING AN INTERPRETER.
BUT FOR EVERYTHING ELSE, DAILY
HOSPITAL CARE FOR EXAMPLE,
GETTING BY IS AN ACCEPTABLE
SHORT CUT.
AND I THINK THAT WHAT THIS HAS
TO DO WITH IS REALLY PREMISE
PREMISED IMPLICITLY ON THESE
PATIENTS SHOULD BE GRATEFUL FOR
THEIR CARE.
AND THEY ARE IMPLICITLY VALUE
THE EXPERIENCE OF THESE PATIENTS
LESS THAN THE EXPERIENCE OF
PATIENTS WHO SPEAK ENGLISH.
AND SO ONE OF THE THINGS THAT I
HAVE STARTED DOING NOW THAT IT
IS A LITTLE BIT EASIER TO DO
THAT IS NAMING THIS FOR WHAT IT
IS.
IT'S A LACK OF INTERPRETER
ACCESS AND LACK OF INTERPRETER
INFRASTRUCTURE IS AN EXCELLENT
CLEAR CUT EXAMPLE OF STRUCTURAL
RACE IMP AND CARE THAT THEN IS
SUPPORTED BY CLINICIAN GOING ON
WITH THAT.
SO IF YOU LOOK AT A CLASSIC
MODEL OF WHAT EXPLAINS
HEALTHCARE DISPARITY, CLEARLY
THERE IS CLINICIAN ACCEPTANCE OF
LESS OF A SHORT CUT THAT THEY
KNOW HARMS PATIENTS IF IT'S INTO
THIS BOX.
BUT ALSO JUST AS CLEARLY IT IS
THE OPERATION OF THE HEALTHCARE
SYSTEM THAT NEEDS TO BE THOUGHT
ABOUT.
I'M NOT GOING GO THROUGH THIS
BUT THIS IS A JOURNEY MAP TO
USING AN INTERPRETER WITH AN LEP
PATIENT STARTING WITH THE
PATIENT SELF-IDENTIFIES OR
CLINICIAN IDENTIFIES THE NEED
FOR AN INTERPRETER AND ALL THE
DIFFERENT STEPS THAT NEED TO BE
DONE.
AND WE USED HERE IMPLEMENTATION
DO MAIN TO CALL OUT HOW MUCH OF
THIS IS ON THE INDIVIDUAL LEVEL,
HOW MUCH IS ON THE HEALTHCARE
ORGANIZATION LEVEL AND HOW MUCH
OF THIS FALLS CLEARLY INTO THE
IMPLEMENTATION PROCESS.
IT IS ALSO IMPORTANT TO NOTE
THAT THERE IS IMPLEMENTATION
MODELS CALL AN OUTER AREA AS
WELL.
AND THAT HAS TO DO WITH WHETHER
OR NOT INTERPRETER SERVICES NOT
ONLY HAVE POLICIES AROUND THEM
BUT THAT THOSE POLICIES ARE
AUDITED AND THAT IN TURN IS
SUPPORTED BY MECHANISMS SUCH AS
QUALITY CONTROL FROM THE JOINT
COMMISSION, ETC.
SO IT IS IMPORTANT TO NOTE THAT
INTERVENTIONS THAT HAVE FOCUSED
SOLELY ON EDUCATING CLINICIANS
TO USING INTERPRETERS HAVE
REALLY NOT WORKED.
THE HASSLE FACTOR IS TOO BIG.
THE INTERVENTIONS THAT HAVE
WORKED ARE INTERVENTIONS SUCH AS
FROM THE ROBERT JOHNSON PROJECT
WHICH USED ALL OF THESE
MULTIMODAL INTERVENTIONS TO
INCREASE INTERPRETATION SUCH AS
CAPTURING PATIENT LANGUAGE
PREFERENCE, CAPTURING THE
INTERPRETER USE IN CLINICAL
RECORD WHICH IS NOT DONE
AUTOMATICALLY NOW, IMPROVING
ACCESS TO LANGUAGE CAN
CLINICIANS BY ASKING IF THEY
WISH TO BE PLACED WITH A
LANGUAGE COORDINATION CLINICIAN.
EASE OF INFRASTRUCTURE WHICH HAS
TO DO WITH REORGANIZING AND
FUNDING.
ADEQUATE LEADERSHIP AND CLEAR
POLICIES.
MOST PLACES DO NOT HAVE CLEAR
POLICIES PARTLY BECAUSE THEY ARE
NOT MANDATED EXTERNALLY.
FOR EXAMPLE, IT IS MY BELIEF
THAT THAT FUR SICK ENOUGH TO BE
IN THE HOSPITAL, YOU SHOULD HAVE
YOUR ABILITY TO TALK WITH A
DOCTOR.
WE DON'T HAVE A POLICY THAT
PATIENTS SHOULD HAVE ACCESS --
THAT PATIENTS SHOULD RECEIVE
COMMUNICATION FROM THEIR
CLINICAL TEAM WHEN HOSPITALIZED
AS A NATIONAL POLICY.
AND I BELIEVE THAT MOST HOSPITAE
HAVE NOT STUDIED THIS, DO NOT
HAVE THAT AS A POLICY.
WE DON'T HAVE ACCESS TO AUDITS
OF THAT USE.
AS WELL AS DIGITAL TOOLS THAT
WOULD INCREASE INTERPRETER
ACCESS OR DIGITAL TOOLS THAT
WOULD PERMIT AUDITING OF
ADHERENCE.
WE ALSO HAVE NO FINANCIAL
INCENTIVES OR PENALTIES FOR
ORGANIZATIONS THAT DO NOT --
THAT DO A GREAT JOB WHEN USING
THIS DESPITE THE FACT THIS WOULD
BE A CLEAR TIE IMPROVE SUCH AN
IMPORTANT HEALTHCARE DISPARITY.
AND FINALLY, AS YOU KNOW, WE ARE
WAY BEHIND WHERE WE NEED TO BE
IN HAVING A LINGUISTICALLY
CULTURALLY DIVERSE WORK FORCE
AMONG PHYSICIANS, AMONG NURSES,
RAIDOLOGY TECHS A AMONG ALL
ASPECTS OF THE COMPLEX
DEVELOPMENT OF THE DELIVERY OF
HEALTHCARE.
SO WITH THAT IN MIND, LET'S MOVE
TO WHAT HAPPENS WHEN YOU DO USE
AN INTERPRETER.
HERE IS THE QUESTION FOR ALL OF
YOU AND YOU CAN PUT THE ANSWER
IN THE CHAT OR YOU CAN JUST
THINK THE ANSWER TO YOURSELF.
DURING AN ENCOUNTER WITH A
PROFESSIONAL INTERPRETER, HOW ON
AVERAGE IS PATIENT COMPREHENSION
COMPARE TO ENCOUNTERS WITH
LANGUAGE CONCORDN'T POSITION?
PATIENT USING AN INTERPRETER AND
YOU ARE SAYING IF I USE A
PROFESSIONAL INTERPRETER, WILL
THE PATIENT UNDERSTAND ME?
IS IT ABOUT THE SAME?
IS IT A LITTLE LESS?
IS IT SOMEWHAT LESS OR A LOT
LESS?
I'LL GIVE YOU A MINUTE TO THINK
WHAT THE ANSWER IS.
AND THE ANSWER IS ACTUALLY A LOT
LESS.
THIS HAS BEEN A DIFFICULT ISSUE
TO STUDY.
IT HAS BECOME CLEAR THAT IN
INTERPRETIVE CONVERSATION WITH
PROFESSIONAL INTERPRETER, THE
SAME THING I'VE SPENT THE FIRST
FEW MINUTES ADVOCATING FOR AND
MAKING THE CASE THAT WE NEED TO
DO BETTER, INTERPRETEDDIVE
CONVERSATIONS RESULT IN LESS
COMMUNICATION.
HOW DO WE KNOW THIS?
WE KNOW IT FROM STUDIES LIKE
THIS ONE FROM BELIVEAU.
THIS IS NOT ONE OF MY STUDIES.
THIS STUDY DONE IN BELIVEAU.
PEOPLE WANTED TO STUDY TWO
INTERPRETER SYSTEMS.
THEY WANTED TO COMPARE AN
INTERPRETER BY THE BEDSIDE
VERSUS REMOTE INTERPRETATION
SYSTEM.
SO WHAT HAPPENED?
THEY TOOK PATIENTS COMING IN TO
THE E D.
AND THEY SAW WHO THEY WERE
ASSIGNED TO.
AND THEY WERE ASSIGNED TO A
LANGUAGE DOCTOR, OBVIOUSLY THEY
DIDN'T NEED AN INTERPRETER.
ALL THESE PATIENTS DON'T SPEAK
ENGLISH.
OTHERWISE THEY COULD COMPARE THE
EXPERIENCE OF PATIENTS WITH ONE
SYSTEM OR ANOTHER SYSTEM BY
ASKING PATIENTS AS THEY LEFT THE
ER DID THEY UNDERSTAND THE
DOCTOR'S EXPLANATION OF WHAT WAS
WRONG WITH THEM AND DID THEY
UNDERSTAND WHAT THEY NEEDED TO
DO TO TAKE CARE OF THEMSELVES.
AND AS THEY LEFT, FEWER THAN
40 PERCENT WHO WERE TAKEN CARE
OF WITH ONE OF THESE STATE OF
THE ART SYSTEMS UNDERSTOOD THE
DOCTOR'S EXPLANATION.
AND FEWER THAN 40 PERCENT
UNDERSTOOD THE CARE INSTRUCTION.
WHAT WAS INTERESTING IS WHAT A
HUGE GAP THAT IS BETWEEN THE
PEOPLE WHO HAD SEEN A LANGUAGE
CONCORDANT DOCTOR WAS AROUND
60 PERCENT.
YOU CAN SAY AND I HOPE SOME ARE
SAYING WOW, ONLY 60 PERCENT OF
THE PATIENTS UNDERSTOOD WHAT
THEY NEEDED TO DO.
AND THIS IS WITH A DOCTOR THAT
SPEAKS THEIR LANGUAGE?
RIGHT.
WE ARE TERRIBLE AT COMMUNICATING
OUR PATIENTS.
AND WE DO NOT ADDRESS CAREFULLY
ENOUGH OUR COMMUNICATION STYLE
TO THE PATIENTS AND WE DO NOT IN
A ROUTINE MANNER ASSESS FOR
PATIENT UNDERSTANDING.
SO WE CLEARLY HAVE A LOT TO DO
WITH WHEN WE DO SPEAK THE SAME
LANGUAGE AS OUR PATIENT.
THE POINT THAT I'M TRYING TO
MAKE SURE IS THAT ROMP MENTION,
EVEN WITH REALLY GREAT
INTERPRETERS IN A GREAT SYSTEM
IS MUCH LESS WHEN PATIENTS ARE
USING PROFESSIONAL INTERPRETER.
I'VE BEEN STUDYING SOME OF THIS
ATAXIESER IN NORTHERN
CALIFORNIA.
EXCELLENT SYSTEM OF CARE WHICH
HAS PROFESSIONAL
INTERPRETERRINGST AVAILABLE AT
ALL OF THEIR SITES.
AND HERE WE SURVEYED ENGLISH
SPEAKING LATINOS, LATINOS WITH
LAP, LIMITED ENGLISH PROFICIENCY
AND ABOUT A QUARTER OF THEM
REPORTED LACK OF TRUST IN THEIR
DOCTORS.
1/3 REPORTED DOCTORS DON'T SHOW
RESPECT AND 1/3 REPORTED DOCTORS
DON'T LISTEN TO THEM WELL.
DO NOT LISTEN.
MORE PATIENTS THAT WERE LEP
REPORTED BEING TREATED POORLY
BECAUSE OF LANGUAGE.
WHAT WAS THEN INTERESTING IS WE
TOOK THESE PATIENTS WHO ARE
DON'T SPEAK ENGLISH AND
SEPARATED THEM INTO PEOPLE WHO
SEE A LANGUAGE CONCORDANT
PRIMARY CARE DOCTOR AND PEOPLE
WHO SEE A LANGUAGE DISCORDANT
PRIMARY CARE DOCTOR, WHICH IS
SOMEONE WHO DOES NOT SPEAK THEIR
LANGUAGE.
AND WHAT WE FOUND IS THAT THE
TRUST WAS -- THE REPORTS OF LACK
OF TRUST WERE MUCH LESS IN
PEOPLE WHO SAW A DOCTOR THAT
SPEAKS THEIR LANGUAGE.
SO WAS DISRESPECT AND SO FEELING
TREATED POORLY BECAUSE OF
LANGUAGE.
AND SO WAS THE FEELING THAT THE
MD DID NOT SHOW THEM RESPECT.
AND THESE ARE VERY LARGE
DIFFERENCES.
THAT SAID, ABOUT 1/3 OF ALL OF
OUR PATIENTS THINK THAT WE DON'T
LISTEN, DO A GOOD JOB LISTENING
TO THEM IRRESPECTIVE OF WHETHER
OR NOT WE SPEAK THEIR LANGUAGE,
THEY ARE PROBABLY RIGHT ABOUT
THAT.
SO THE THING THAT THIS STUDY
SHOWED AND MANY OTHER STUDIES
HAVE SHOWN THAT IT IS VERY
DIFFICULT TO ELICIT TRUST AND TO
ELICIT PATIENT FEELING RESPECTED
ACROSS A LANGUAGE BARRIER.
WHY IS THIS?
IT'S PARTLY BECAUSE USE OF AN
INTERPRETER ALTERS WHAT I'M
GOING TO CALL THE COMMUNICATION
ARCHITECTURE.
IN THE RELATIVELY FEW STUDIES
THAT HAVE EXAMINED HOW PATIENTS
ARE WHAT HAPPENS IN AN
INTERPRETED CONVERSATION,
STUDIES THAT HAVE AUDIO TAPED
DOCTORS AND PATIENTS TALKING
WITH AN INTERPRETER.
WHAT IT'S FOUND IS THAT PATIENTS
TALK A LOT LESS BETWEEN DOCTOR
TALKING AND THE INTERPRETER
TALKING, PATIENTS TALK A LOT
LESS.
SECOND, PHYSICIANS ARE LESS
LIKELY TO ELICIT THE PATIENT'S
POINT OF VIEW.
I VERY MUCH KNOW HOW EASY IT IS
TO MAKE THIS MISTAKE.
I TAKE CARE OF A LOT OF PATIENTS
WITH DIABETES.
I'M SO FOCUSED ON TAKE YOUR MEDS
TWICE A DAY, YOU TAKE THE
CHOLESTEROL PILL ONCE A DAY.
IT'S IMPORTANT TO TAKE BOTH OF
YOUR BLOOD PRESSURE MEDICATIONS
IN THE MORNING.
I'M SO FOCUSED ON MAKING SURE
THAT I'M COMPREHENDING THAT MY
INSTRUCTIONS TO THE PATIENTS ARE
CLEAR THROUGH PROFESSIONAL
INTERPRETER THAT I FORGET TO SAY
HOW DO YOU FEEL ABOUT TAKING A
MEDICINE FOR THE METAPHOR
MINUTE.
HOW DO YOU FEEL ABOUT TAKING A
CHOLESTEROL MEDICINE?
WHAT ARE YOUR QUESTIONS ABOUT IS
THAT THAT?
IN THAT WAY MY CARE BECOMES MUCH
LESS PATIENT CENTERED.
NOT BECAUSE I'M A BAD PERSON OR
DON'T RESPECT MY PATIENTS BUT
BECAUSE THE NEED TO SPEAK WITH
AN INTERPRETER PUSHES ME TO A
NARROWER MUCH MORE MEDICAL
CONVERSATION IN WHICH I LEAVE
LITTLE ROOM TO ELICIT THE
PATIENT'S POINT OF VIEW OR THEIR
CONCERNS.
I'LL TELL YOU ANOTHER STORY.
I WAS PRECEPTING IN OUR CLINIC.
AND WE HAVE TO GO IN AND OBSERVE
PATIENT CONVERSATIONS FROM TIME
TO TIME.
I DID THAT A FEW YEARS AGO WITH
A RESIDENT WHO IS AN EXCELLENT
RESIDENT.
AND HE WAS SPEAKING WITH A
CANTONESE SPEAKING PATIENT WITH
AN INTERPRETER.
HE WAS LOOKING AT THE COMPUTER
AND HE SAID I SEE YOU MISSED
YOUR APPOINTMENT WITH THE
PULMONARY DOCTOR OR PULMONARY
SPECIALIST.
AND THE PATIENT SAID YES.
MY MOTHER DIED.
AND THE DOCTOR TURNED BACK TO
THE COMPUTER AND SAID OK I'LL
MAKE YOU ANOTHER APPOINTMENT
WITH THEM.
NOW IS IT BECAUSE THIS WAS A
YOUNG DOCTOR WHO WAS
OVERWHELMED?
MAYBE.
BUT WHAT HAPPENS IS THAT AGAIN
WE BECOME VERY BIO MEDICALLY
FOCUSED.
VERY FOCUSED ON TASKS.
IT TURNS OUT THAT IN THE
LITERATURE FOR EXAMPLE ON TRUST
BETWEEN AFRICAN-AMERICAN
PATIENTS AND THEIR DOCTORS, IT
TURNS OUT THAT THE EMPATH I CANC
REMARKS IS USUAL TO TRUST.
I THINK THIS DIDN'T HAPPEN
BECAUSE OF THE PRESENCE OF THE
INTERPRETER.
BECAUSE THIS WAS AN -- BECAUSE
THIS AGAIN PUSHED WARD THE LET'S
GET IT DONE.
SOME PLACES HAVE REACTED BY
GIVING MORE TIME FOR
CONVERSATIONS THAT ARE MEDIATED
TO AN INTERPRETER.
BUT BILLING SYSTEMS TEND NOT TO
SUPPORT THAT AND THE PLACES THAT
HAVE DONE THAT HAVE R VERY FEW.
AND THEN ON TOP OF THAT, MOST
PEOPLE ARE NOT THE SCIENCE OF
WHAT HAPPENS IN INTERPRETIVE
CONVERSATIONS.
THIS IS AN AREA WHERE WE NEED
MUCH MORE RESEARCH SO THAT WE
CAN START TEACHING FOLKS REALLY
WHAT TO LOOK FOR AND HOW THE
WORK WELL WITH AN INTERPRETER.
SOME OF YOU WILL RECALL A FEW
YEARS AGO WHAT BECAME REALLY
IMPORTANT WHERE SHOULD AN
INTERPRETER STAND, SHOULD THEY
STAND BEHIND THE PATIENT.
THOSE QUESTIONS MIGHT BE
IMPORTANT.
WHAT WE KNOW LITTLE ABOUT AGAIN
IS WHAT ACTUALLY HAPPENS.
WE HAVE NOT PUT IN THE RESOURCES
TO ENABLE PEOPLE TO UNDERSTAND
MORE ABOUT INTERPRETIVE
CONVERSATION.
SO TO SUM MARRIZE WHILE UNDER
USE OF INTERPRETER IS COMMON AND
NORMALIZED, WE'RE QUITE CLEAR
THAT INTERPRETIVE CONVERSATION
OFTEN RESULT IN LESS
COMPREHENSION AND TRUST AND
PATIENT SATISFACTION ARE MUCH
LOWER WHEN CARE TENDS TO GO
ACROSS A LANGUAGE BARRIER.
LET'S TURN NOW TO CLINICAL
IMPACTS.
I THINK SOME OF THIS IS FAMILIAR
TO YOU.
PATIENTS REPORTED MORE
MEDICATION ERRORS.
THEY ARE MUCH MORE LIKELY NOT TO
UNDERSTAND THEIR PRESCRIPTION
LABELS ABOUT GETTING BETTER AS
BOTH THE LARGE NATIONAL CHAINS
AND INDEPENDENTS ARE STARTING TO
PUT PRESCRIPTION LABELS IN MANY
COMMON LANGUAGES.
HOWEVER THEY ARE LESS LIKELY TO
KNOW WHAT THEIR MEDICATIONS ARE
AT HOSPITAL DISCHARGE AND LESS
LIKELY TO KNOW ABOUT THE
FOLLOWUP APPOINTMENTS THAT HAVE
ALREADY BEEN MADE.
AND ON TOP OF THAT LANGUAGE
BARRIERS HAVE BEEN IMPLICATED IN
PATIENT SAFETY EVENTS BECAUSE OF
PROCEDURES BEING SHORT CIRCUITED
BECAUSE OF LANGUAGE BARRIERS
SUCH AS TIMEOUT PROCEDURES TO
VERIFY THAT THE PERSON IS --
THAT THE PATIENT IS THE RIGHT
PERSON OR TO ASK AGAIN ABOUT
HOSPITAL ALLERGIES.
WHAT I WANT TO TALK ABOUT ARE
SPECIFIC CLINICAL OUTCOMES I.
WANT TO TURN HERE TO DIABETES.
AS YOU PROBABLY KNOW, DIABETES
CARE IS CONTROL IS MUCH WORSE
AMONG LATINOS VERSUS WHITES.
AND WHITES HERE ARE THE VERY
LAST BAR.
AND THIS IS DATA FROM -- AND ALL
OF THIS OTHER DATA ARE FROM THE
STUDY OF LATINOS.
AND WHILE WE SEE VARIATION, THE
CUBANS HAVING BETTER GLUE SEEMIC
CONTROL.
NONE OF THESE ARE AS GOOD AS THE
WHITE GROUP.
WE BECAME VERY INTERESTED IN
THIS QUESTION BECAUSE I WANTED
TO SEE WHAT ROLE LANGUAGE
BARRIERS SAY IN POOR GLUCOSE
CONTROL IN WITH DIABETES.
I HAD FORTUNE OF WORKING WITH
ANDY CARTER AND A GROUP WHERE WE
SURVEYED 20,000 PATIENTS IN FIVE
LANGUAGES INCLUDING ENGLISH AND
SPANISH AND ALSO WERE ABLE TO
EXTRACT DATA FROM THEIR
FANTASTIC ELECTRONIC DATA SET.
WHAT WE FOUND IS WE LOOKED AT
LATINO PATIENTS WHO SPOKE
ENGLISH AND LATINO PATIENTS WITH
LIMITED ENGLISH PROFICIENCY.
WHAT WE FOUND IS THOSE PATIENTS
WERE PRETTY SIMILAR IN TERMS OF
THEIR AGE, PRESENTATION.
BUT THEY WERE VERY DIFFERENT IN
THEIR EDUCATION LEVEL.
ABOUT 70 PERCENT OF THE ENGLISH
SPEAKERS HAD FINISHED HIGH
SCHOOL.
WHERE 70 PERCENT OF THE SPANISH
SPEAKERS OR LEP SPEAKERS HAD NOT
FINISHED HIGH SCHOOL.
AND THEY WERE ALSO VERY
DIFFERENT IN THE AMOUNT OF MONEY
THEY MADE WITH PEOPLE WHO WERE
LEP MAKING LESS MONEY.
WHEN WE TOOK THE GROUP OF PEOPLE
BY LEP AND DIVIDED THEM UP INTO
WHETHER OR NOT THEIR DOCTORS,
PRIMARY CARE DOCTORS SPOKE
SPANISH, LANGUAGE CONCORDANT OR
NOT, WE FOUND THAT THEY ACTUALLY
LOOKED PRETTY SIMILAR ON PAPER.
THERE WERE VERY FEW DIFFERENCES
BETWEEN THEM.
BUT THEN WHEN WE LOOKED AT THEIR
GLUCOSE CONTROL, WE FOUND VERY
LARGE DIFFERENCES.
AMONG THE WHITE ENGLISH
SPEAKERS, 10 PERCENT AT AHEM
GLOBEN A1C OVER 9.
LATINO ENGLISH SPEAKERS
18 PERCENT HAD A A1C OVER 9.
AMONG THE LEP THAT WAS
21 PERCENT.
AGAIN WHEN WE DISAGGREGATE THE
LEP INTO THOSE WITH A LANGUAGE
CONCORDANT DOC AND THOSE
WITHOUT, WE FOUND LARGE
DIFFERENCES.
ABOUT 16 PERCENT HAD VERY POOR
GLUCOSE CONTROL WHICH WAS AS
GOOD AS A LATINO ENGLISH
SPEAKER.
AND 28 PERCENT OF PEOPLE WHO IS
DOCTOR DID NOT SPEAK SPANISH HAD
POOR GLUCOSE CONTROL.
THESE DIFFERENCES HELD TRUE
AFTER ADJUSTING PHYSICIAN,
PHARMACY, ETC.
THE ODDS RATIO WAS ALMOST TWO
COMPARED TO A LATINO ENGLISH
SPEAKER OF PATIENTS WHO WERE
SPANISH SPEAKERS AND DID NOT
SEEK A SPANISH SPEAKING DOCTOR.
WE THEN LOOKED AT THE SAME
COHORT AND SAID WELL WHAT ABOUT
LIPID, ARE WE GOING TO SEE THAT
DIFFERENT?
WHAT ABOUT BLOOD PRESSURE, ARE
WE GOING TO SEE THAT DIFFERENCE?
WHAT WE WANT TO POINT OUT THERE
WERE SOME SMALL DIFFERENCES BUT
THERE WERE NO LARGE DIFFERENCES,
SIGNIFICANT DIFFERENCES IN THE
GROUP IN LIPID CONTROL OR BLOOD
PRESSURE CONTROL.
SO THIS IS VERY INTERESTING.
BECAUSE IT STARTS TO TEACH US
ABOUT WHERE LANGUAGE BARRIERS
APPEAR TO PLAY A BIG ROLE AND
WHERE LANGUAGE BARRIERS MAYBE
DON'T PLAY SUCH A BIG ROLE.
MAYBE IT'S ENOUGH THAT I SAY TO
MY CANTONESE SPEAKING PATIENT
TAKE THE MEDICINE EVERY DAY.
AND HE OR SHE UNDERSTANDS THAT.
AND THEN I'M KIND OF DONE WITH
LIPID CONTROL.
MAYBE GLUCOSE CONTROL WHICH IS
SO MUCH MORE COMPLICATED IS
DIFFERENT.
SO IN WAS A CROSS SECTIONAL
STUDY.
LIKE ALL CROSS SECTIONAL
STUDIES, ARE SUBJECT TO MANY
CONFOUNDERS.
IN THE IDEAL WORLD YOU WANT TO
TAKE A BUNCH OF LEP PATIENTS AND
GIVE YOU A DOCTOR THAT SPEAKS
YOUR LANGUAGE OR DOESN'T SPEAK
YOUR LANGUAGE.
THAT IS DIFFICULT TO DO.
BECAUSE I DON'T THINK PATIENTS
WANT TO BE RANDOMIZED.
WE ALREADY KNOW THAT TRUST,
RESPECT AND OTHER PATIENT
CENTERED OUTCOMES ARE DIFFERENT.
SO WE DECIDED MAYBE THE BEST WAY
TO STUDY THIS IS BY STUDYING
NATURAL EXPERIMENTS.
SO WE LOOKED AT SWITCHES.
WE TOOK DATA OF NORTHERN
CALIFORNIA AND WE LOOKED AT
SWITCHES FROM A DISCORDANT
DOCTOR TO A CONCORDANT DOCTOR.
AND WE SAID ONE YEAR LATER WHAT
HAPPENS TO THEIR A1C?
IT TURNS OUT THAT THE ONLY
SWITCH THAT WAS EXTREMELY
SIGNIFICANT WAS WHEN PEOPLE
SWITCHED FROM A DOCTOR THAT
DIDN'T SPEAK SPANISH TO A DOCTOR
THAT SPEAKS SPANISH.
AND MORE OF THEM GOT INTO GOOD
CONTROL WITH AN A1C UNDER 8 AND
FEWER OF THEM HAD A1CS OVER 9.
THIS IS REALLY PORN.
THIS SHOWS US THAT LANGUAGE
MATTERS A GREAT DEAL FOR A1 C.
IT ALSO HAS IMPORTANT POPULATION
HEALTH OR REGISTRY HEALTH
IMPLICATION.
WHY IS THAT?
BECAUSE THESE SWITCHES HAPPEN
WITHIN KAISER.
NO NEW RESOURCES WERE USED.
THESE FOLKS GOT BETTER JUST
BECAUSE THEY SWITCHED TO A
DOCTOR THAT SPOKE THEIR
LANGUAGE.
WHEN WE LOOK AT WHETHER OR NOT
THAT WAS TRUE FOR LIPIDS OR SIS
TOLLIC BLOOD PRESSURE, NO IT WAS
NOT.
THE SWITCHES ALL RESULTED IN
IMPROVEMENT WHERE PATIENT --
WHERE I THINK PATIENTS WHO HAD
SOMEHOW GOTTEN OFF THEIR STATTEN
HAVING GOOD BLOOD PRESSURE
CONTROL WERE SEEN AGAIN AND THE
PHYSICIAN IMPROVED THAT CARE.
THESE WERE NONSIGNIFICANT BY
LANGUAGE IN ANY COMBINATION.
SO THAT IS REALLY AGAIN STARTING
TO SHOW US THAT LANGUAGE
BARRIERS IMPACT SOME CLINICAL
OUTCOMES AND DON'T IMPACT OTHER
CLINICAL OUTCOMES.
AND THIS HAS IMPLICATIONS FOR
HOW WE MAY ORGANIZE OUR HEALTH
SERVICES.
WHAT ABOUT ADHERENCE?
WE LOOKED AT THAT AGAIN.
AND WHAT WE FOUND WAS THAT
ENGLISH SPEAKING LATINOS HAVE
MUCH WORSE ADHERENCE TO DIABETES
MEDS THAN THEIR WHITE PATIENTS,
MUCH MORE LIKELY TO BE POOR
ADHERENCE.
LEP PATIENTS WERE EVEN MORE
LIKELY TO HAVE POOR.
BUT THAT ADHERENCE DID NOT
DIFFER BY VIRTUAL WHETHER OR NOT
THE DOCTOR SPOKE THEIR LANGUAGE.
SO YOU CAN SAY WAIT A MINUTE.
ADHERENCE DOESN'T DIFFER.
THIS STUDY DOESN'T GIVE US THE
ANSWER TO THAT.
IN MY VIEW IT'S BECAUSE OF TWO
THINGS.
ONE, WE WERE UNABLE TO LOOK AT
INSULIN AND I THINK THAT WHEN
THE PHYSICIAN SPEAKS THEIR
LANGUAGE, THEY CAN -- IT'S
EASIER TO PERSUADE PATIENTS TO
USE INSULIN.
AND SECOND THAT WHEN PEOPLE
SPEAK THE LANGUAGE, THERE IS
BOTH MORE TIME AND INTEREST IN
BEING ABLE TO ADDRESS DIET AND
LIFESTYLE MODIFICATION SUCH AS
PHYSICAL ACTIVITY.
AND ONE OF THE THINGS THAT WE
SEE IS AGAIN, BACK TO MY
EXPERIENCE WITH NON-SPANISH
SPEAKING PEOPLE WITH PATIENTS
WITH DIABETES, WE BECOME MORE
BIO MEDICALLY FOCUSED, WE PUSH
DRUGS MORE AND TALK TO THE
PATIENT A LOT LESS AND EXPRESS
AND ELICIT A LOT LESS THEIR
QUESTIONS ABOUT DIET.
IT IS IN THIS WAY WHERE I THINK
ALSO THAT CULTURAL COMPETENCE
BECOMES VERY HELPFUL IN TERMS OF
FOR EXAMPLE ELIMINATING OR
REDUCING SUGAR SWEETENED
BEVERAGES FOR PEOPLE WITH
DIABETES.
WHERE WE CAN SAY YOU SHOULD NOT
DRINK SODA, ETC. THAT PEOPLE USE
WITHOUT THINKING ABOUT IT AS
BAD.
HOW TO SUM MARRIZE THIS,
ADHERENCE ORAL MS IS NOT
DIFFERENT BUT GLUCOSE CONTROL IS
BETTER LIKELY COMBINATION TO
MAKE MORE CHANGES, MORE MEDICAL
CHANGES.
OVERALL WHAT WE FIND IN PATIENTS
WITH DIABETES WHO AS IT IS
SUFFER FROM DEPRESSION AND
DIABETES TREMENDOUS, IT IS CLEAR
FROM STUDIES THAT THERE IS LESS
STRESS TRUST, LESS COMPREHENSION
WITH THEIR CARE.
WHAT DO WE NEED TO DO?
INTENTIONALLY ADDRESS THAT BY
ASSESSING COMPREHENSION TO
THINGS LIKE TEACH BACK.
WE NEED TO INTENTIONALLY ADDRESS
MAKING IMPACT STATEMENT.
WE NEED TO ELICIT PATIENT POINT
OF VIEWS ON RECOMMENDATION.
AND LET ME TAKE A MINUTE TO SAY
THIS IS NOT ONLY TRUE WITH
GLUCOSE CONTROL, IT'S TRUE WITH
OTHER HEALTH SERVICES THAT ARE
EASIER AND ALSO REQUIRE TRUST
AND MOTIVATION.
IN SAN FRANCISCO, WE DID THE
CITY DID COVID CONTACT TRACING.
AND THEY TOOK LIBRARIANS AND
THEY HAD LIBRARIANS DO A LOT OF
THE CONTACT TRACING.
SO HIGHLY EDUCATED, VERY
INTELLIGENT PEOPLE, CARING
PEOPLE.
AND SOME OF THEM SPOKE SPANISH
AND SOME OF THEM DID NOT.
AT THE SAME TIME WE ALSO PUT
INTO THE FIELD AND MY GROUP WAS
THE ONE THAT DID THIS, I'M VERY
PROUD OF THAT.
WE WORKED WITH COMMUNITY BASED
ORGANIZATIONS TO CREATE -- TO
TEACH SPANISH SPEAKERS TO DO
CONTACT TRACING.
WHAT WE FOUND IS WHEN THE
SPANISH SPEAKING LIBRARIANS OR
THE COMMUNITY BASED FOLKS THAT
SPOKE SPANISH WERE THE ONES WHO
APPROACH AID PATIENT, IT TURNED
OUT THAT MANY MORE OF THE
PATIENTS WENT ON AND THEIR
FAMILY MEMBERS WENT ON TO GET
TESTED THEMSELVES.
THE LIBRARIANS, PEOPLE WHO SPOKE
ONLY ENGLISH AND DID THIS
INTERACTION VIA INTERPRETER,
PEOPLE LISTENED TO THEM BUT THEY
WERE MUCH LESS LIKELY TO ACT ON
THEM.
I THAT'S A NICE EXAMPLE IN A
MUCH MORE STRAIGHTFORWARD, 15,
20 MINUTE INTERACTION.
BUT STILL AN INTERACTION THAT
REQUIRES TRUST AND REQUIRES
MOTIVATION.
A PATIENT MOTIVATION OF THE
IMPORTANCE OF LANGUAGE
CONQUERENS AND HOW IMPORTANT IT
IS THAN EVEN PROFESSIONALLY
MEDIATED INTERPRETER
INTERACTION.
WHERE DOES THAT LEAVE US?
I'VE BEEN INTERESTED IN LOOKING
AT MACHINE INTERPRETATION AND
SPOKEN LANGUAGE.
WHEN I THOUGHT ABOUT WHAT IS IT
WE WANT.
WHAT IS THE GREAT TOOL?
WHAT SHOULD WE REALLY WANT?
IT BECAME CLEAR WHAT WE WANTED
WAS THIS.
I HOPE THERE IS A FEW OF YOU
THAT ARE STAR TREK FANS OUT
THERE.
I LOVED STAR TREK OF ALL THE
STAR TREKS.
AND THIS IS WHAT CAPTAIN KIRK IS
HOLDING HERE IS A UNIVERSAL
TRANSLATOR.
WHEN THEY ENCOUNTER A NEW
SPECIES IT WOULD START WORKING
AND WHATEVER LANGUAGE THE
SPECIES SPOKE IT WOULD COME OUT
IN ENGLISH AND WHATEVER THE TEAM
WANTED TO SAY WOULD COME OUT IN
PERFECT CLING ON.
THIS IS WHAT WE WANT.
WE WANT TO HOLD SOMETHING IN OUR
HANDS AND MAKE IT WORK
FLAWLESSLY.
HOW FAR AWAY ARE WE?
WELL, WE DID THIS STUDY AND
AGAIN THIS IS AN UNFUNDED STUDY.
MANY OF THEM ARE OF MY STUDIES.
ALL THE KAISER WORK WAS FUNDED.
BUT IN TERMS OF FUNDING FOR
BASIC RESEARCH INTO
COMMUNICATION, THAT HAS REALLY
NOT BEEN THERE.
AND HERE WHAT WE DID IS THAT WE
WENT TO OUR CLINICAL RECORDS AND
WE TOOK 100 DISCHARGE
INSTRUCTIONS.
SOME FROM OUR EMERGENCY ROOM
HERE AT SAN FRANCISCO GENERAL
AND SOME FROM OUR EMERGENCY ROOM
AT UCSF HEALTH WHICH IS MORE OF
A CLASSIC ACADEMIC CENTER.
AND WE PUT ALL OF THESE
INSTRUCTIONS INTO A GLOBAL
TRANSLATE IN SPANISH.
AND WE PUT THEM ALL THROUGH INTO
CHINESE.
AND THEN WE ASKED PROFESSIONAL
INTERPRETERS WHO WERE BLINDED TO
BACK TRANSLATE FROM THE SPANISH
OR BACK TRANSLATE FROM THE
CHINESE.
AND THIS IS WHAT THEY TOLD US.
IN THE ORIGINAL SENTENCE FOR
EXAMPLE IT SAYS TOLD KIDNEY
MEDICINE UNTIL YOU HAVE A CHANCE
TO SPEAK WITH YOUR KIDNEY
DOCTOR.
THE SPANISH SAID KEEP THE
MEDICINE FOR THE KIDNEY UNTIL
YOU HAVE A CHANCE TO TALK WITH
YOUR KIDNEY DOCTOR BECAUSE THEY
TRANCE ITED HOLD AS HOLD ON,
KEEP.
GOOGLE TRANSLATE DID.
THAT WAS PROPOTENTIALLY LIFE
THREATENING AND THAT WAS ALSO
TRUE FOR THE CHINESE.
ADDITIONALLY IT WORKS LESS WELL
IN CHINESE.
BUT IT DOESN'T WORK WHEN THE
PHYSICIAN USES A NORMAL WORD
LIKE HOLD IN AN ATYPICAL MANNER.
THE PROBLEM HERE IS NOT THE
GOOGLE TRANSLATE.
THE PROBLEM HERE IS THE DOCTOR.
THEY SHOULDN'T HAVE WRITTEN THE
KIDNEY MEDICINE.
BUT THE POINT IS THAT'S WHAT
THEY DID.
IT ALSO CAN'T HANDLE
ABBREVIATIONS OR SMELLING AND
GRAMMATICAL ERRORS.
FAIRLY STRAIGHTFORWARD.
THE CLINICIAN WROTE PLEASE TAKE
THIS MEDICATION AS FOLLOWS.
AND HERE THE SPAWNISH IS PRETTY
GOOD BUT THE LIED CAIN PATCHES
ARE NOT ON FOR 12 HOURS.
AND SO.
AND IN THE CHINESE IT REALLY
ALSO HAD A LOT OF DIFFICULTY
TRANSLATING.
WE RECOMMENDED THAT PEOPLE NOT
USE GOOGLE TRANSLATE EXCEPT IF
THEY ARE VERY CAREFUL TO USE
SIMPLE PLAIN LANGUAGE AND IF
THEY DO, TO ALWAYS DROP IN HAVE
AN AUTOMATIC DROP IN THIS WAS
MACHINE TRANSLATED AND THAT THE
ENGLISH IS THE REAL VERSION.
SO WHEN PEOPLE TAKE HOME THINGS,
IF IT DOESN'T MAKE SENSE THEY
CAN GET SOMEONE TO READ IT FOR
THEM IN ENGLISH.
RIGHT NOW WE ARE REPEATING THIS
STUDY WITH CHAT GPT TO SEE
WHETHER OR NOT THAT MAKE ACE
DIFFERENCE WHEN WE USE A MORE
ACTIVE ARTIFICIAL INTELLIGENCE
MACHINE TRANSLATION MODEL.
AND THEN I MENTOR ANOASOLOGIST,
A YOUNG SCIENTIST WHO IS IS
INTERESTED IN BEING ABLE TO USE
PHONE INTERPRETERS IN THE OR
ITSELF.
THESE ARE AREAS WHERE THE
INTERACTIONS ARE VERY BRIEF AND
WHERE OFTEN THE DEFAULT IS TO
USE NOTHING AT ALL AND NOT TALK
WITH THE PATIENT AT ALL RATHER
THAN THEY DON'T SEE IT AS WORTH
THEIR TIME TO CALL A
PROFESSIONAL INTERPRETER AND IT
CAN BE HARD TO GET PHONES GENTOO
THE O R.
WE AGAIN LOOKED AT SPANISH AND
HERE WE LOOKED AT MANDARIN.
AND WE TOOK SENTENCES FROM THESE
WERE ALL LOW RISK SENTS SUCH AS
CAN I GO TO THE BATHROOM NOW OR
WIGGLE YOUR TOES OR OTHER THINGS
THAT EITHER TER PATIENT WANTS TO
SAY OR THAT THE CLINICIAN WANTS
TO SAY.
AND WE LOOKED AT THREE MODELS,
APPLE, GOOGLE AND MICROSOFT AND
COMPARED IT TO A HUGE
INTERPRETATION.
AND THEN WE HAD THOSE
INTERPRETATIONS RATED BY PEOPLE
WHO ARE BILINGUAL SPEAKERS AND
PROFESSIONALS WHO WERE BLINDED
AS TO HOW THE INTERPRETATION WAS
MADE.
AND WHAT WE FOUND IS WE SET UP
PARAMETERS FOR ACCEPTABILITY.
AND WHAT WE FOUND IS THAT THE
THREE PROGRAMS WERE ABOUT
70 PERCENT ACCEPTABLE WHICH IS
NOT BAD IN ENGLISH TO SPANISH.
THOUGH IT DOESN'T I DON'T SAY A
MARGIN.
THEY WERE LOUSY AT INTERPRETING
SPANISH TO ENGLISH.
LET ME TELL YOU WHY.
IT TURNS OUT WHEN WE LOOKED AT
THE SENTENCE AND AT THE OTHERS,
WHAT HAPPENED IS IF THE PATIENT
SAID WHY DOES MY LEG HURT.
THE MACHINE WOULD INTERPRET THAT
AS AND WOULD SAY BECAUSE MY LEG
HURTS.
INSTEAD OF ASKING WHY DOES MY
LEG HURT.
THE PATIENT WOULD BE SAYING
BECAUSE MY LEG HURTS.
AND THAT IS CLEARLY NOT
ACCEPTABLE.
AND THIS WAS EVEN IN ENGLISH TO
MANDARIN WAS LESS GOOD THAN
ENGLISH TO SPANISH.
BUT AGAIN, LITTLE BIT BETTER
THAN A LOT BETTER THAN MANDARIN
TO ENGLISH WHERE THE
ACCEPTABILITY RANGED FROM 30 TO
40 PERCENT.
UNFORTUNATELY THE UNIVERSAL
TRANSLATOR IS NOT HERE YET.
WE ARE TRYING TO FIGURE OUT AND
OTHER PEOPLE ARE WORKING THIS AS
A GROUP IN BOSTON WORKING ON
THIS TO SEE WHETHER OR NOT THERE
IS A WAY IN WHICH FOR VERY LOW
RISK SITUATIONS PATIENTS SIGN
IN.
PATIENTS GOING TO RAIDOLOGIST
WHERE THE TECH HAS TO SAY
WELCOME, PUT YOUR THINGS DOWN
HERE, TURN AROUND FOR THE X-RAY.
AND INSTEAD OF SHOVING PEOPLE
AROUND, WILL THERE BE A USE FOR
THESE MACHINE INTERPRETATIONS?
I'M CONFIDENT THAT THE TIME WILL
COME WHEN THIS WILL WORK OUT.
BUT WE ARE NOT ANYWHERE NEAR
THERE YET.
SO IN SUMMARY, I HOPE I'VE SHOWN
THAT YOU LANGUAGE BARRIERS
REALLY CONTRIBUTED TO HEALTHCARE
DISPARITIES.
AND HERE THE CLINICAL MOD UNTIL
DIABETES WORKS WELL BOTH IN
CONTRIBUTION TO POOR GLUCOSE
CONTROL AND ALSO IN
CONTRIBUTIONS TO THE PATIENT
EXPERIENCE.
THAT WHEN YOU DO USE IN
PROFESSIONAL INTERPRETER HEALTH
CARE TEND TO BE LESS PATIENT
CENTERED AND MANY COMPLEX
OUTCOMES THAT REQUIRE PATIENT
UNDERSTANDING, BUY IN AND TRUST
ARE MUCH WORSE.
WHERE AS OTHERS APPEAR NOT TO BE
AFFECTED.
WE NEED DO A LOT MORE TO
FACILITATE LANGUAGE ACCESS AND
ALSO WE NEED A LOT MORE RESEARCH
TO DETERMINE HOW TO IMPROVE IT
AND HOW LANGUAGE BARRIERS AFFECT
PATIENT OUTCOMES AND PATIENT
EXPERIENCE.
JUST TO NAME A FEW, WHEN IS
LANGUAGE CONCORDANCE NEEDED?
CAN WE GET BY WITH JUST
PROFESSIONAL INTERPRETERS.
WHAT ABOUT AT DISCHARGE, WHAT
ABOUT BEHAVIORAL COUNSELING?
WE DON'T KNOW THE ANSWER TO
THAT.
WE DON'T KNOW THE ANSWER TO
WHERE MACHINE TRANSLATION CAN
IMPROVE THE PATIENT EXPERIENCE.
MAYBE THE TRANSLATOR IS NOT VERY
GOOD OR MACHINE INTERPRETATION
IS NOT GOOD BUT MAYBE IT CAN
IMPROVE EXPERIENCE IN RIDE
RAYEDOLOGY.
FINALLY WE NEED FUNDAMENTAL
VERGE INTO PATIENT CLINICIAN
COMMUNICATION AND WHAT IS THE
ARCHITECTURE OF INTERPRETER
COMMUNICATIONS AND WHAT
INTERVENTIONS CAN WE USE TO
IMPROVE THE PATIENT CENTEREDNESS
AND THE EFFECTIVENESS OF THOSE
COMMUNICATIONS?
WITH THAT LET ME JUST STOP HERE.
AND I HOPE THAT YOU'VE ENJOYED
THIS AND THAT WE CAN HAVE A
LITTLE BIT OF CONVERSATION.
>> THANK YOU SO MUCH.
THAT WAS OUTSTANDING.
REALLY GREAT TO HEAR YOUR
PERSPECTIVE ON THIS RELATIVELY
NARROW TOPIC BUT REALLY
IMPORTANT AND ONE THAT WE'VE
SHARED INTEREST IN AND
COLLABORATED ON A COUPLE OF
TIMES ON THIS.
I WANTED TO START US OFF WAY
COUPLE OF QUESTIONS AND SHELLY
IS GOING TO GATHER QUESTIONS
FROM THE VIDEO CAST SO WE'LL GO
TO HER AND SEE WHAT WE HAVE.
WE TECHNICALLY HAVE UNTIL 3:30.
SO WE WON'T HOLD YOU UNTIL THEN
UNLESS THERE IS LOTS OF
QUESTIONS THAT REQUIRE THAT.
>> YES WE GO UNTIL 3:30 AND WE
DO HAVE QUESTIONS.
>> I LOVE THE FACT HOW YOU ENDED
IT.
I THINK I'LL PUT A PLUG IN FOR A
OPPORTUNITY THAT NIMHD HAS OUT
ON PATIENT CLINICIAN
COMMUNICATION.
THIS IS THE KIND OF RESEARCH I
THINK THAT IN THE PAST PEOPLE
HAVE CONSIDERED EITHERRER NOT
SCIENTIFIC ENOUGH OR SOFT.
WE REALLY THINK IT'S AT THE CORE
CONTRIBUTOR TO HEALTHCARE
DISPARITIES.
SO NOT JUST IN THE LANGUAGE
BARRIERS WHERE YOU HAVE VERY
QUAN QUANTITATIVE THINGS TO
MEASURE BUT ALSO IN GENERAL THAT
WHOLE IDEA OF TRUSTING EXAMPLES
YOU GAVE I THINK WERE QUITE
ILLUSTRATIVE IN THAT WAY.
YOU MENTIONED TECHNOLOGY QUITE A
BIT.
I'M GLAD YOU SHARED THE WORK YOU
DID WITH THE TRANSLATORS.
I KNEW THAT HAPPENED.
I DIDN'T REMEMBER THE OUTCOME.
AND IT'S BETTER THAN NOTHING SI
GUESS WHAT WE'RE SAYING.
BUT IT IS WAY INADEQUATE AND
POTENTIALLY COULD CAUSE HARM.
AND IN SOME WAYS THE
PROFESSIONAL INTERPRETERS ARE
DEFINITELY BETTER THAN NOTHING
AND THEY FILL A VOID BUT THEY
ARE FAR FROM THE IDEAL OR THE
GOLD STANDARD WHICH WOULD BE
TALK TO SOMEONE WHO DIRECTLY
UNDERSTANDS YOU.
WHAT ABOUT THE VIDEO ACCESS?
HAS THAT BEEN MORE PROMINENTLY
DISSEMINATED?
BECAUSE ONE OF THE LIMITATIONS
WITH INTERPRETERS WAS THEY HAD
TO RUN AROUND, THE COST AND THEY
ARE SITTING AROUND WAITING FOR
TO YOU FINISH.
WHAT HAS BEEN YOUR EXPERIENCE
WITH THE EITHER VIDEO OR PHONE
TRANSLATORS?
>> THERE HAS BEEN A FAIR NUMBER
OF STUDIES ON THE USE OF VIDEO
COMPARING VIDEO, PHONE AND IN
PERSON INTERPRETATIONS.
AND VIDEO AND IN PERSON ARE
RANKED EQUALLY WHICH IS
FANTASTIC BY PATIENTS AND BY
CLINICIANS.
THAT IS FANTASTIC NEWS.
BECAUSE VIDEO IS MUCH MORE
EFFICIENT.
INTERPRETER IS NOT RUNNING
AROUND THE HOSPITAL.
THEY ARE SITTING AT THEIR DESK
AND THEY CAN GO FROM ONE VIDEO
CALL TO ANOTHER INDIVIDUAL CROW
CALL.
WHY DO PATIENTS LOVE VIDEO
INTERPRETATION?
THEY LOVE IT BECAUSE IT'S LESS
INTRUSIVE.
THE PERSON IS LESS IN THE ROOM.
AND IT'S MORE A PART OF THE
HEALTHCARE TEAM WITHOUT BEING SO
IN THE ROOM.
AND I THINK THAT ALSO HAS BEEN
REALLY HELPFUL.
UNFORTUNATELY MOST HOSPITALS
DON'T HAVE ACCESS TO VIDEO
INTERPRETATION.
THAT'S CHANGING.
BECAUSE OF THE CLIMATE FOR TYPE
OF INTRANET, EITHER NET,
SOMETHING I DON'T UNDERSTAND IN
ORDER TO HAVE VIDEO
INTERPRETATION.
OR BECAUSE OF THERE SIMPLY
HASN'T BEEN THE INVESTMENT IN
IT.
EVEN THOUGH TECHNOLOGICAL
CHANNELS ARE NOT THERE.
ONE OF THE THINGS THAT HAPPENED
DURING THE PANDEMIC IS BECAUSE
INTERPRETERS -- AS YOU KNOW,
MANY IMMIGRANT PATIENTS
DISPROPORTIONATEDLY AFFECT BID
THE COVID PANDEMIC.
BECAUSE MANY PEOPLE -- BECAUSE
WE WERE TRYING TO BLOCK
HEALTHCARE WORK FREERS GOING
INTO THE ROOM AND EXPOSING
THEMSELVES WHEN IT WASN'T
NECESSARY.
MANY PLACES STARTING USING IPADS
WHERE WE GAVE THE PATIENT AN
IPAD AND THEN THE INTERPRETER
WAS OUTSIDE AND THEY WERE ABLE
TO COMMUNICATE THAT WAY.
AND AGAIN THAT WAS CLEARLY
BETTER.
THE QUESTION IS CAN WE TAKE THAT
THOSE ADVANCES AND MAKE THEM
STATE OF THE ART IN ALL
HOSPITALS?
AND THE ANSWER TO THAT IS THERE
HAS BEEN THAT WE CAN CLEARLY DO
THAT BUT THERE HAS BEEN NO
APPETITE TO DO THAT BY ANY
REGULATORY AGENCY.
BECAUSE OF THE COMBINATION OF
THINKING THAT IMMIGRANTS ARE
LESS IMPORTANT AND NOT BEING
FORCED TO DO IT BY A REGULATION,
AND THAT THIS IS AN UNFUNDED
MANDATE, MOST HOSPITALS INVEST
THE MINIMUM IN INTERPRETER
SERVICES.
SO IT'S A HUGE ISSUE.
BUT WE TO DO NOAH VIDEO
INTERPRETATION IS GREAT.
IT'S MUCH BETTER THAN OTHER
FORMS.
>> THANK YOU.
THIS WOULD BE ONE OF THE THINGS
THAT NEED TO BE THROUGH POLICY
CHANGES, AGENCIES THAT HAVE
LEVERAGE POWER IN THIS CASE CMS
MAKE IT A INDICATOR THEN IT
BECOMES -- WE DO KNOW SYSTEMS
CHANGE WHEN THAT HAPPENS.
THERE IS A QUESTION FROM THE
AUDIENCE.
CAN YOU EXPLAIN ABOUT FAMILY
BEING USED AS INTERPRETERS?
>> GREAT QUESTION.
SO THAT'S ACTUALLY BEEN LOOKED
AT A FAIR AMOUNT.
AND WHAT WE SEE IS THAT FAMILY
MEMBERS OBVIOUSLY HAVE THE BEST
OF INTENTION.
BUT THERE IS TWO ISSUES.
ONE IS FAMILY MEMBERS DON'T HAVE
THE KNOWLEDGE AND SKILLS TO WORK
AS PROFESSIONAL INTERPRETERS.
SO THAT MEANS THAT THEY DON'T
KNOW HOW THE SAY CERTAIN WORDS
BECAUSE THEY HAVE NEVER USED
THOSE WORDS.
AND THERE ZO THERE IS A LOT
OF -- THERE ARE MANY MISTAKES.
INTERESTINGLY THERE ARE ALSO A
LOT OF OMISSIONS.
SO YOU CAN ASK DOES DO YOU HAVE
ANY ALLERGIES AND THE FAMILY
MEMBER WILL SAY NO AND IT TURNS
OUT THAT FAMILY MEMBER DOESN'T
KNOW THAT THE PATIENT HAS
ALLERGIES.
AND THERE IS ALSO STRANGELY
ENOUGH ADDITIONS.
SO IN A FAMOUS SET OF STUDIES IN
PEDIATRICS WHERE THEY RAN AUDIO
TAPES WITH FAMILY MEMBERS
SERVING ADDS INTERPRETEDDERS,
FAMILY MEMBERS WOULD ADD
SOMETHING.
SO FOR EXAMPLE THE DOCTOR SAID
TAKE THE AMOXICILLIN TWICE A DAY
FOR THE KID'S EAR INFECTION.
AND WHAT THE INTERPRETER SAID IS
PUT THE AMOXICILLIN IN THE EAR
TWICE A DAY FOR THE EAR
INFECTION.
IT TURNS OUT AMOXICILLIN GOES IN
THE MOUTH AND NOT IN THE EAR.
IT WAS AN ADDITION.
SO WHAT WE SEE ARE MISTAKES,
OMISSIONS AND ADDITIONS.
SO IN SHORT, WE THERE IS
CONSENSUS THAT FAMILY MEMBERS
SHOULD NOT BE USED AS
INTERPRETERS.
I'LL ADD ONE MORE REASON THAT
DOESN'T HAVE TO DO WITH THE
ACCURACY OF INTERPRETED
INFORMATION.
AND THAT IS THAT EVERYONE
DESERVES TO HAVE THEIR FAMILY
MEMBER BE THERE AS A FAMILY
MEMBER.
SO WHEN PEOPLE BRING IN FAMILY
MEMBERS TO ME TO MY CLINIC I SAY
THANK YOU SO MUCH FOR BEING
HERE.
I'M DELIGHTED.
I'M GOING TO CALL THE
INTERPRETER BECAUSE THAT'S OUR
POLICY.
I'M SO GLAD YOU ARE HERE BECAUSE
IF YOU CATCH SOMETHING OR YOU
WANT TO EXPLAIN SOMETHING MORE
TO ME, YOU CAN DO THAT.
AND SO AGAIN, FAMILY MEMBERS
GREAT ADVOCATES, NOT SO GREAT AS
INTERPRETERS.
>> THANK YOU.
I WILL ADD THAT IT'S BEEN
ACTUALLY MADE ILLEGAL IN SOME
JURISDICTIONS TO HAVE CHILDREN
DO INTERPRETATIONS APPROPRIATELY
SO.
YOU CAN IMAGINE A NON-ENGLISH
SPEAKING ADULT BRINGING IN THEIR
15-YEAR-OLD AND THERE ARE BOUND
TO BE QUESTIONS NOT GOING TO BE
ASKED OR ANSWERED BECAUSE OF THE
PRESENCE OF AN ADOLESCENT OR
YOUNGER ADOLESCENT IN THE ROOM
ACTING AS AN INTERPRETER.
WE REALLY NEED TO AVOID THAT.
ANOTHER QUESTION FROM THE
AUDIENCE FROM ONE OF OUR STAFF
AT NIMHD.
THANKING YOU FOR YOUR VERY
INFORMATIVE PRESENTATION AS A
SCIENTIST, CLINICIAN.
WHAT I'VE NOTICED THAT THE
HEALTHCARE SYSTEM IS A BARRIER
TO PROVIDING QUALITY CARE TO
THESE PATIENTS WHEN THERE IS
PRESSURE TO SEE A LARGE VOLUME
OF PATIENTS THERE IS CONCERNS TO
NOT BE PROPERLY HEARD OR
UNDERSTOOD.
ALSO THE PROVIDERS MAY NOT BE
GIVEN EXTRA TIME DURING CLINICAL
MEETINGS TO PROVIDE GOOD QUALITY
OF CARE.
TO ADD ARE ISSUES OF HEALTHCARE
WORKER BURNOUT.
THIS CALLS FOR POLICY LEVEL
CHANGES.
THAT'S MORE OF A COMMENT THAN A
QUESTION.
>> THAT'S A GREAT COMMENT I
COULD COMPLETELY AGREE.
UCSF IS MADE UP OF THREE LARGE
HOSPITAL SYSTEMS.
ONE OF THE THREE NOT THE ONE I
WORK, IN PRIMARY CARE THEY HAVE
DOUBLE THE AMOUNT OF TIME GIVEN
TO PATIENTS TO CLINICIANS WHO
ARE TREATING A PATIENT WITH AN
INTERPRETER PRECISELY BECAUSE OF
THIS.
WE AT SAN FRANCISCO GENERAL HAVE
NOT DONE THAT.
WHY IS THAT?
BECAUSE OVER 30 PERCENT OF OUR
PATIENTS -- I THINK IT'S MORE
THE PRIMARY CARE IT'S MORE LIKE
50 PERCENT OF OUR PATIENTS DO
NOT SPEAK ENGLISH.
WE CAN'T DO OUR JOB OF TAKING
CARE OF PATIENTS IF WE DOUBLE
THE TIME.
IN THE SYSTEMS THAT HAVE SMALLER
NUMBER OF PATIENTS THAT DON'T
SPEAK ENGLISH IT MAKES A LOT OF
SENSE TO GRANT MORE TIME TO
THOSE INTERACTIONS AND HAVE THAT
REFLECTED IN HOWEVER THE
PHYSICIAN'S WORK IS AUDITED.
SO I COMPLETELY AGREE AND THIS
IS POLICY.
I ALSO THINK THAT AGAIN I AGREE
CMS COULD DO A LOT HERE TO ALIGN
ON THIS AND MAKE BETTER CARE FOR
PATIENTS FOR TAKING CARE OF
PATIENTS WITH LANGUAGE BARRIERS.
>> PARTICULARLY IN AREAS WHERE
THERE IS A THRESHOLD NUMBER OF
PEOPLE WHO ARE LIMBED ENGLISH
PROFICIENCY.
YOU SHOWED THE WHOLE COUNTRY.
THERE IS SEMITRITHERE AND IF
IT'S A REQUIREMENT IT COULD BE
TARGETED.
I THINK YOU SHOWED THE EMPIRICAL
EVIDENCE.
BUT IN ADDITION IF YOU HAVE
SOMEONE WITH AN INTERPRETER, YOU
DO HALF AS MUCH BECAUSE YOU HAVE
HALF THE TIME.
AND AS CLINICIANS YOU REALLY
WORK ON THE GET THE TECHNICAL
THINGS DONE.
YOU CALL THE MEDICAL APPROACH OR
BIO MEDICAL.
TAKE YOUR MEDICINE, MAKE SURE
YOU GET THE TEST.
THAT GENERALLY HAS BEEN SHOWN TO
BE DONE REASONABLY WELL IN THESE
ENCOUNTERS.
BUT YOU TOTALLY LOSE OUT ON
BUILDING RELATIONSHIP, CREATING
TRUST AND WHAT I WOULD CALL THE
SOFT PART OF THIS AND
PARTICULARLY IN A PRIMARY CARE
SETTING WHERE YOU ARE NOT
DEALING WITH ONE PROBLEM IN THE
EMERGENCY ROOM AND SO THIS
REALLY MATTERS.
ANOTHER QUESTION THAT WE HAD
FROM AN OUTSIDE AUDIENCE, YOUR
STATEMENT ON LANGUAGE ACCESS IS
AN EXAMPLE OF STRUCTURAL RACISM.
IT'S SO TRUE AND RESOUNDING.
TALK MORE ABOUT IF TIME ALLOWS.
FOR EXAMPLE HOW CAN WE COMPARE
OTHER SERVICES THAT ARE SIMILAR
THAT ARE PROVIDED WITHOUT
QUESTION VERSUS LANGUAGE ACCESS
ETC.?
FROM ANOTHER PERSPECTIVE, WOULD
WOULD THERE BE MORE ADHERENCE
AND QUALITY OUTCOMES, HOSPITAL
REIMBURSEMENT ETC.?
THIS IS ONE OF YOUR COLLEAGUES
FROM UCSF.
>> THAT'S A COLLEAGUE FROM UC
SAN DIEGO.
I SEE THIS AS STRUCTURAL RACISM.
LET ME GIVE YOU AN EXAMPLE.
PHLEBOTOMY.
IT COST MONEY TO HAVE SOMEONE
THERE TO DRAW LABS OR DRAW BLOOD
CULTURES.
BACK IN MY DAY AND CERTAINLY ALL
THE OLDER CLINICIANS WILL
REMEMBER THIS, THE INTERNS DREW
LABS AND BLOOD CULTURES.
RIGHT NOW THAT DOESN'T HAPPEN.
WE HAVE TEAMS OF PEOPLE GOING
AROUND THE HOSPITAL DRAWING LABS
AND BLOOD CULTURES.
THEY NEED TO BE PAID.
WE HAVE ROLLED PAYMENT COST OF
THOSE FOLKS UP INTO THE TEST.
WE NEED TO GET THE LABS AND THAT
MEANS SOMEONE NEEDS TO DRAW THE
BLOOD.
IN THE SAME WAY I CALL THIS
RACISM AS OPPOSED TO SIMPLY BAD
MEDICAL CARE BECAUSE IT'S
OBVIOUS THAT WE NEED TO FULLY
FUND LANGUAGE ACCESS SERVICES TO
MAKE IT MUCH MORE SEAMLESS SUCH
AS WE WERE SAYING WITH IPADS
ETC. FOR BOTH MORE SEAMLESS FOR
THE DOCTOR AND THE PATIENT.
AND SOMEONE HAS TO PAY FOR IT.
AT THE END OF THE DAY SOMEONE
HAS TO PAY FOR IT.
BUT IN THE SAME WAY THAT WE
FIGURE OUT HOW THE PAY FOR THE
HOSPITAL LIGHTS, HOW TO PAY FOR
THE PHLEBOTOMIST.
WE CAN FIGURE OUT HOW TO PAY FOR
ROBUST LANGUAGE ACCESS SERVICES.
THE FACT THAT WE DON'T DO THIS,
THE FACT THAT ALMOST ALL REALLY
STRONG INTERPRETATION SYSTEM
VERSUS BEEN PUT THIS PLACE AS A
RESULT OF LAWSUITS NOT AS A
RESULT OF PRACTICE SPEAKS TO A
CERTAIN LACK OF UNDERSTANDING,
LACK OF APPRECIATION OF THESE
PATIENTS EXPERIENCE AND NEEDS.
AND THAT IS NOT A SCIENTIFIC
BLOCK.
THAT IS SOMETHING ELSE.
AND THERE WAS A MOMENT HERE IN
THE PANDEMIC WHEN LOOKING AROUND
THE COUNTRY AND GETTING THE
REPORTS OF HOW DISPROPORTIONATE
THE IMPACT OF THE PANDEMIC WAS
ON IMMIGRANT LATINOS AND OTHER
IMMIGRANTS AS WELL AS
AFRICAN-AMERICANS, I TURNED TO A
COLLEAGUE AND SAID WE'RE GOING
TO GET LANGUAGE SERVICES OUT OF.
THIS PEOPLE ARE GOING TO SEE
THESE ESSENTIAL WORKERS DESERVE
THE MINIMUM INFRASTRUCTURE TO BE
ABLE TO GET GOOD CARE.
I DON'T THINK WE'RE GOING TO GET
LANGUAGE SERVICES.
I THINK THE PANDEMIC IS FOR NOW
LOOKS MUCH MORE MANAGEABLE.
AND THAT PEOPLE DID NOT -- THERE
HASN'T BEEN A SOCIAL ACCOUNTING
FOR WHO ALL ENDED UP DYING
DURING THIS PANDEMIC.
BECAUSE THEY WERE ESSENTIAL
WORKERS AND HOW THE HEALTHCARE
SYSTEM SHOULD RESPOND.
I WAS WRONG ABOUT THAT.
BUT I THINK THAT IS WHAT IS
HAPPENING.
AND IF PEOPLE DON'T DO IT
BECAUSE OF HOSPITAL SYSTEMS
DON'T PUT IT INTO PLACE BECAUSE
IT'S BETTER CARE AND SHOULD JUST
BE PART OF CARE, THEN ONLY WAY
THIS WILL HAPPEN IS ON THE
REGULATORY SIDE.
ON THE REGULATORY SIDE PEOPLE
HAVE BEEN RELUCTANT, REGULATORY
ORGANIZATION ARE RELUCTANT.
FOR EXAMPLE MY WORK WAS PART OF
THE IMPETUS FOR THIS.
THEY DO MONITOR WHETHER OR NOT
INTERPRETERS ARE USED FOR
INFORMED CONSENT.
WHEN IT GOES INTO A HOSPITAL
VISIT THEY WILL PULL A CERTAIN
NUMBER OF CHARTS AND LOOK AT
WHETHER OR NOT THERE IS
DOCUMENTATION OF INTERPRETER
USE.
FANTASTIC.
BUT THEY ARE NOT MONITORING FOR
EXAMPLE A PATIENT SPENT FIVE
DAYS IN THE HOSPITAL, ON HOW
MANY DAYS DID A CLINICIAN
ACTUALLY TALK WITH A PATIENT
USING AN INTERPRETER.
WE SHOULD BE ABLE TO MONITOR
THAT.
>> THANK YOU.
AND JUST FOR THE AUDIENCE.
ANOTHER YES I REALLY APPRECIATE
ALL THE INSIGHTS INTO CHRONIC
DISEASE MANAGEMENT MADE FOR
PRIORITIZATION FOR PERSONAL
CONNECTION, IS THERE ANY MODELS
ORGANIZATION, INSTITUTIONS THAT
LEAD OR RESEARCH THE EFFICACY OR
POLICIES OR PRACTICE?
>> OK.
YOUR QUESTION ARE THERE
ORGANIZATIONS THAT STAND OUT FOR
THE WORK THEY DO?
I THINK PROBABLY ONE OF THE
GROUPS THAT IS DOING A REALLY
GOOD JOB IS MASS GENERAL
HOSPITAL.
DURING PANDEMIC THEY DID A
REALLY GREAT JOB EMBEDDING
LANGUAGE CONCORDANT STAFF INTO
THE TEAMS TAKING CARE OF COVID.
THEY WERE SOME OF THE TEAMS THAT
EXPERIMENTED WITH IPADS.
I'M SURE I'M NOT AN EXPERT AT
MGH BUT THEY HAVE MORE TO DO AND
THERE ARE PEOPLE THERE WORKING
ON THIS.
BUT THAT SAID, THEY HAVE HAD
HOSPITAL LEADERSHIP FROM THE
VERY TOP DOWN THAT HAS BEEN
COMMITTED TO ENDING DISTIS.
HEALTHCARE DISPARITIES.
UNFORTUNATELY VERY FEW C.E.O.S
OF HOSPITAL VERSUS BEEN THAT
COMMITTED TO ENDING HEALTHCARE
DISPARITIES.
DISPARITIES ARE NOT SHOWN ON
HOSPITAL C.E.O. DASH BOARDS.
USUALLY SO AND SO IS A NICE GUY
OR WOMAN AS OPPOSED TO ARE THEY
TRULY COMMITTED TO HENNING
HEALTHCARE DISPARITIES.
I THINK THAT IS WHERE YOU KNOW
OF THE REASONS WHY MGH HAS BEEN
HEAD AND SHOULDERS ABOVE OTHER
INSTITUTIONS WHICH ISN'T TO SAY
THAT THEY HAVE A LOT OF WORK TO
DO.
>> THANK YOU.
AND I'M BEING TOLD WE HAVE LOTS
OF QUESTIONS.
WE'RE NOT GOING TO GET TO ALL OF
THEM.
WE'LL SEE WHAT WE CAN PLOW
THROUGH.
I'LL PAUSE TWO OR THREE MINUTES
BEFORE 3:30.
THIS IS A COMMENT FROM BREN DA
WHO IS THE MANAGER OF THE
LANGUAGE INTERPRETER PROGRAM AT
THE NI H.
SHE SAYS WE PROVIDE SERVICES ON
SITE BY TELEPHONE AND TELEHEALTH
LANGUAGE ACCESS IS A PATIENT
RIGHT AND NOT PROVIDING SERVICES
DOES CONSTITUTE A HEALTHCARE
DISPARITIES.
THANK YOU BREN DA.
YOU HAVE ANOTHER QUESTION
SHELLY?
>> HOW MIGHT TRAIN COMMUNITY
PEER EDUCATORS HELP COORDINATE
TEACHING IN THE FACILITY AND THE
HOME OF THE MEMBER VIDEO OR IN
PERSON?
THESE COURSES COULD BE TAUGHT BY
SPEAKERS OF THE LANGUAGE,
TRAINED AND AVAILABLE TO TEACH A
STANDARD COURSE OF INFORMATION.
THEY DO NOT GIVE MEDICAL ADVICE,
ONLY INFORMATION.
>> I THINK THAT WHAT THE
QUESTIONER IS DESCRIBING IS
COMMUNITY HEALTH FIRST.
I'M A FINAL FAN.
PEOPLE CAN GO INTO THE HOME AND
GIVE LANGUAGE CONCORDANT
INFORMATION TO PATIENTS.
THE COCHRAN COLLABORATIVE MORE
RESEARCH NOT NEEDED IN TERMS OF
WORKERS FOR TEACHING PEOPLE
ABOUT DIABETES CONTROL AND EVEN
FOR HYPERTENSION CONTROL.
AND COMMUNITY HEALTH WORKERS ARE
PARTICULARLY EFFICACIOUS,
EFFECTIVE IN WORKING WITH
SPANISH SPEAKING COMMUNITIES.
NEED MORE RESEARCH ON OTHER
LANGUAGES.
I COULDN'T AGREE WITH YOU MORE.
AND NOT ONLY DO I AGREE, MOST
IMPORTANTLY CMS HAS BEEN
PERSUADED BY THIS.
AND CMS IS NOW SAYING THAT
HOSPITAL SYSTEMS CAN BILL FOR
COMMUNITY HEALTH WORKER
ENCOUNTERS.
I MENTIONED BEFORE THIS MEETING
WHAT IS HARD IS FOR SYSTEMS TO
GEAR UP TO BILL.
ONCE WE CAN GEAR UP TO BILL AND
WE CAN WORK WITH COMMUNITY
COLLEGES, CBO GROUPS TO TRAIN
COMMUNITY HEALTH WORKERS, I
THINK THIS WILL BE A VERY
IMPORTANT EXPANSION OF THE WORK
FORCE.
SO THE BILLING IS NOW SET UP.
AND NOW IT'S TIME FOR PEOPLE TO
TAKE ADVANTAGE OF IT.
>> THANK YOU.
QUESTION ABOUT ARE THERE DATA
BASES THAT ARE AVAILABLE AT THE
NATIONAL LEVEL SUCH AS CLAIMS
THAT ARE USE TO FEEL EXAMINE THE
BILLING OF MEDICAL INTERPRETERS?
>> FANTASTIC QUESTION.
NO, THERE ARE NOT.
WHAT HAPPENS IS THAT YOU CAN GET
FROM A PARTICULAR HEALTHS
SYSTEM.
WE PAY FOR THIS MANY MINUTES PER
MONTH FOR INTERPRETER SERVICES.
YOU CAN GET A BREAKDOWN OF THE
LANGUAGES AND SO ON.
WHAT YOU CANNOT GET IS DID SO
AND SO RECEIVE AN INTERPRETER ON
THIS DATE IN THIS INTERACTION.
AND THAT IS AN AREA WHERE PEOPLE
WHO MANUFACTURE ELECTRONIC
RECORDS AND OTHER SOURCES REALLY
NEED TO STEP UP.
WE HAVE TO BE ABLE TO SEAMLESSLY
CLICK ONE BUTTON AND IT IDENTIFY
INTERPRETER WAS USED AN WHO THE
INTERPRETER WAS AND HOW LONG
THAT INTERPRETATION LASTED.
THIS CANNOT BE THAT -- THIS
CAN'T BE THAT HARD.
AND YET THIS IS AN AREA WHERE
AGAIN MEDICAL RECORDS HAVE THE
POTENTIAL BUT HAVE NOT REALIZED.
>> ANOTHER QUESTION HOW IS VRI
TRANSLATEDDERSES WORKING WITH
TRANSLATOR SERVICES?
>> I'M NOT ENTIRELY SURE WHAT
VRI IS.
BUT WHAT IS IMPORTANT IS IT
ISN'T EASY -- LET ME TAKE A STEP
BACK.
TELEHEALTH AS YOU ALL KNOW HAS
TREMENDOUS POTENTIAL TO BE ABLE
TO IMPROVE CARE FOR OUR
PATIENTS.
IT MAKES LIFE MUCH EASIER FOR
THE PATIENT NOT TO HAVE TO COME
IN.
IF I'M DOING SOMETHING LIKE
TITRATING INSULIN LEVELS OR
BLOOD PRESSURE MEDICATIONS AND I
CAN ASK THE PATIENT WHAT THEIR
NUMBERS ARE, I DON'T NEED TO SEE
THEM IN THE OFFICE, I NEED TO
HAVE A CONVERSATION WITH THEM.
WHAT HAPPENS IF I'M TRYING TO DO
THAT IN A INTERPRETIVE
CONVERSATION?
WELL, IT'S REALLY HARD.
NOW I'VE LOST -- IF I'M DOING IT
BY TELEPHONE, I'VE LOST THE
VISUAL QUEUE THE PATIENT AS WELL
AS WITH THE INTERPRETER.
EVEN IF I HAD THE INTERPRETER ON
THE PHONE ROUTINELY AND THE
INTERPRETER KNOW HOES TO YOU
WORK THE PHONE, I'VE LOST THE
VISUAL CUE AND THAT IS HARD.
BECAUSE I'M NOT REALLY SEEING
WHERE THE PATIENT WANTS TO TALK
MORE OR THEY ARE SHOWING THEY
DON'T UNDERSTAND AND SO ON.
THE FIX TO THAT IS VIDEOTAPE.
WHERE YOU HAVE THE PATIENT ON
THE VIDEO, INTERPRETER AND
PHYSICIAN ON THE VIDEO.
SOME SYSTEM VERSUS MANAGED TO
PUT THAT IN PLACE.
WHAT IS HARD IS SO MANY OF OUR
PATIENTS DON'T HAVE ACCESS TO
VIDEO SERVICES.
OR IF THEY DO, ARE NOT ALLOWED
TO USE THEM.
FOR EXAMPLE YOU PROBABLY ALL
KNOW THAT LATINOS, IMMIGRANT
LATINOS HAVE ONE OF THE HIGHEST
PENETRATIONS OF SMARTPHONES IN
THE COUNTRY.
BECAUSE THEY WANT TO CALL HOME.
EVERYONE, EVEN MY PATIENTS WITH
THE THIRD GRADE EDUCATION KNOW
THOUSAND USE WHAT'S APP OR FACE
TIME.
THAT CAN ALLOW ME TO USE VIDEO.
I'M NOT ALLOWED TO USE THAT
BECAUSE IT'S NOT PROTECTED
ENOUGH.
FROM COMPLIANCE POINT OF VIEW.
IT'S PUT ME IN A VERY STRANGE
POSITION OF SAYING TO MY BOSSES,
IT IS MORE IMPORTANT TO THE
PATIENT AND TO ME THAT WE HAVE A
CONVERSATION WHERE WE CAN SEE
EACH OTHER THAN THE SMALL CHANCE
SOMEBODY WILL FIND OUT MR. CHOW
HAS DIABETES.
HE DOESN'T CARE AND I DON'T
CARE.
BUT UNFORTUNATELY THE MEDICAL
LEGAL SYSTEM DOESN'T WORK THAT
WAY.
AND I'M INTERESTED IN HEALTH
CARE DISPARITIES BROADLY.
ONE OF THE THINGS I HOPE YOU ARE
GETTING FROM THIS TALK IS HOW
SOMETHING THAT SEEMS SO EASY,
LET'S IMPROVE LANGUAGE ACCESS
SERVICES TOUCHES SO MANY ASPECTS
OF BILLING, MEDICAL LEGAL WITHIN
OUR COMPLEX SYSTEM.
>> I'LL ASK THIS ONE MORE
QUESTION RELATED TO THIS.
WHAT ROLE COULD AI, ARTIFICIAL
INTELLIGENCE PLAY IN
FACILITATING INTERPRETATIONS?
COULD THAT INCREASE
AVAILABILITY?
>> THANK YOU.
YES.
WE ARE STUDYING THAT NOW.
FOR EXAMPLE, WE WANT TO BE ABLE
TO PROVIDE HOSPITAL DISCHARGE --
I SHOWED STUDY ON ER DISCHARGE
INSTRUCTIONS.
WE WANT TO BE ABLE TO PROVIDE
HOSPITAL DISCHARGE INSTRUCTIONS
IN A PATIENT'S LANGUAGE F. WE
PAY AN INTERPRETER THAT TAKES A
CERTAIN AMOUNT OF TIME.
THEY HAVE TO BE CERTIFIED IN
TRANSLATION AND INTERPRETATION.
IT KEEPS THEM FROM DOING OTHER
THINGS.
SO THE QUESTION IS CAN AI DO
THAT OR CAN AI DO THAT AND THEN
HAVE THAT OVERREAD BY AN
INTERPRETER?
IN THE SAME WAY THAT THE EKG
MACHINE WILL READ THE EKG AND
THIS CAN BE HELPFUL.
BUT WE STILL RELY ON A POSITION
TO OVERREAD THE EKG MACHINE.
SO RIGHT NOW WE'RE GOING TO SET
UP A STUDY UNFUNDED IN WHICH WE
ARE LOOKING AT WHETHER OR NOT A
SYSTEM OF HAVING AI DO IT FIRST
AND THEN OVERREAD, HOW MUCH MORE
EFFICIENT IS THAT THAN JUST
HAVING THE TRANSLATOR TRANSLATE?
BECAUSE I THINK THAT IT IS IN
THOSE MINUTES OF INTERPRETER
TIME THAT WE WILL SEE TO WHAT
EXTENT IS THIS WORKING?
HOW EFFICIENT IS IT?
>> THANK YOU SO MUCH LISA
SAPINSLEY.
-- ALICIA MOST OFTHE DATA YOU S
RELATED TO SPANISH.
AND YOU EASILY JUSTIFY WITH
61 PERCENT OF PEOPLE WHO DON'T
SPEAK ENGLISH AT HOME SPEAK
SPANISH.
OF THE GROUP THAT DON'T.
WHAT IS THE NATURE OF THE OR THE
STATUS OF EMPIRICAL WORK IN
NON-SPANISH LEP?
>> VERY SMALL.
VERY SMALL.
BECAUSE AS YOU KNOW DOING THIS
WORK IS EXPENSIVE.
YOU NEED BILINGUAL RESEARCH
ASSISTANTS.
YOU ALSO NEED TO PAY
PROFESSIONAL INTERPRETERS,
PROFESSIONAL TRANSLATORS TO
EVALUATE SOMETHING.
OFTEN THE RESEARCH GROUP ITSELF
HAS TO BE ABLE TO READ
TRANSCRIPTS OR LISTEN TO AUDIO
TAPES AND IN THAT CASE IN ORDER
TO DO SOMETHING, YOU NEED A
MULTILINGUAL BIO MEDICAL
SCIENTIFIC WORK FORCE.
AND WHO IS INTERESTED IN THESE
QUESTIONS.
UNFORTUNATELY THE LITERATURE ON
OTHER LANGUAGES HAS LAGGED
BEHIND SPANISH.
I'M VERY LUCKY TO WORK WITH SOME
ASIAN COLLEAGUES WHO ARE ABLE TO
AND WE'RE ABLE TO WORK TOGETHER.
AND THAT'S WHY WE'RE DOING WORK
THAT INCLUDES MANDARIN AND
CANTONESE AS WELL AS SPANISH.
THE TRUTH OF THE MATTEDDER IS
THERE NEEDS TO BE ROBUST FUNDING
STRAINS JUST LIKE NIH INVESTED
IN OTHER AREAS THAT ALLOW PEOPLE
TO CREATE THE GROUPS THAT ARE
NECESSARY MUCH IN THE SAME WAY
THAT OTHER SCIENTIFIC QUESTIONS
REQUIRE MULTIDISCIPLINARY
MULTISKILLED RESEARCH TEAMS.
>> THANK YOU.
AND THE LAST COMMENT I'LL MAKE
AND LET YOU EXPAND ON IT.
AT LEAST FOR THE WORK FORCE,
THERE IS AN OFFICE OF THE NIH
DIRECTOR CHIEF OFFICE OF THE
SCIENTIFIC FOR WORK FORCE
DIVERSITY THAT WAS STARTED AND
THEN HANNA VALENTINE WAS THE
FIRST PERSON AND NOW IT'S MARIE
BERNARD.
I KIND OF SEE IN THE CONTEXT OF
THE SUPREME COURT DECISION ON
COLLEGE ADMISSIONS AND THE USE
OF RACE AND ETHNICITY AND SEX OR
GENDER ARE CONSIDERED IN THE
SAME CATEGORY AS NOT BEING ABLE
TO USE THOSE IN TERMS OF
CONSIDERATION AS A FACTOR IN
COLLEGE ADMISSION AND HOWTA WILL
APPLY TO OTHER FIELDS, WHAT
ABOUT LANGUAGE FLUENCY?
DOESN'T IT MAKE SENSE THAT SINCE
WE DON'T GET ENOUGH PEOPLE
SPEAKING SPANISH FOR EXAMPLE
THAT THAT BE A FACTOR CONSIDERED
IN MEDICAL SCHOOL OR RESIDENCY
SELECTION?
>> ABSOLUTELY.
IT IS A SKILL.
AND SAYING WE VALUE SOMEONE A W
A HIGHER MKAT MORE THAN SOMEONE
WITH A LOWER MKAT BECAUSE WE
THINK THAT IS REPRESENTATIVE OF
A FUND OF KNOWLEDGE THAT IS A
GOOD COMPONENT OF BEING A GOOD
DOCTOR.
WE THINK THAT COMMUNITIES THAT
MEDICAL SCHOOL ADMISSIONS SHOULD
PRIVILEGE PEOPLE WHO HAVE JUST
LIKE THE MKAT DOCUMENTED
EXPERTISE IN A PARTICULAR
LANGUAGE OF INTEREST FOR THAT
MEDICAL SCHOOL.
WHETHER IT'S ONE OR WHETHER IT'S
SPANISH, THEY SHOULD BE ABLE TO
SAY WOW, THIS IS A SPEAKER, WE
SHOULD TAKE A SECOND LOOK AT
THIS APPLICANT.
I DON'T THINK IT'S ENOUGH FOR
PEOPLE TO SELF-CERTIFY.
I SPEAK SPANISH.
MAYBE YOU DO.
MAYBE YOU DON'T.
I DO THINK THERE NEEDS TO BE A
PROCESS WHERE YOU ARE ABLE TO
SHOW YOUR KNOWLEDGE.
BUT I DO THINK THAT PUTTING THAT
INTO PLACE BIPASSES SOME OF THE
SUPREME COURT'S CONCERNS ABOUT
SOCIAL FACTORS THAT THEY DO NOT
BELIEVE SHOULD INCREASE
ADMISSIONS BY PUTTING IT
SQUARELY WHERE THAT BELONGS AS A
SKILL.
SOME PEOPLE HAVE IT, SOME PEOPLE
DON'T.
WE SHOULD PRIVILEGE THAT.
THAT SAID, I DON'T WANT ANYONE
THINKING THAT I DON'T BELIEVE
THAT LANGUAGE -- THAT CULTURAL
CONCORDANCE ISN'T HUGELY
IMPORTANT.
WE HAVE AMPLE EVIDENCE OF THE
DIFFERENCE IN RELATIONSHIP
BETWEEN BLACK PHYSICIANS AND
THEIR PATIENTS ON HOW IMPORTANT
THAT IS IN TERMS OF PATIENT
TRUST AND SELECTED PATIENT
OUTCOMES.
AND SO THEN AGAIN, THIS IS NOT
ABOUT -- THIS IS TRULY ABOUT
WHAT SOMEONE CAN BRING TO THE
TABLE THAT WILL IMPROVE PATIENT
CARE.
UNFORTUNATELY IN CALIFORNIA
WE'VE HAD OVER 20 YEARS OF
DEALING WITH CROP 290 WHICH
PROHIBITED CONSIDERATIONS OF
RACE IN FEDERALLY FUNDED
ADMISSIONS IN ALL PUBLIC
UNIVERSITIES.
SO ALL OF THE UCS I, WE KNOW HOW
BAD THIS BE.
WE KNOW UC BERKELEY AND UCLA
HAVE NEVER RECOVERED FROM THE
DROP IN STUDENTS AND THAT IS
HORRENDOUS.
THE MEDICAL SCHOOLS HAVE FIGURED
OUT HOW TO BRING IN PEOPLE BASED
ON THEIR SKILLS, BACKGROUNDS AND
INTEREST WHICH ARE IMPORTANT THE
MEET CALIFORNIA'S REQUIREMENTS.
SO WE ARE HOPE HALF OTHER
MEDICAL SCHOOLS WILL BE ABLE TO
DO THE SAME.
BUT WE WILL ALL BE FRUSTRATED BY
THE IMPACT ON THE PIPELINE
PARTICULARLY ON THE ELITE
COLLEGES AND UNIVERSITIES.
>> WITH THAT WE'RE SLIGHTLY OVER
3:30 SO WE SHOULD TOP.
I WANT TO THANK YOU ALICIA FOR A
WERE WONDERFUL TALK.
I LEARNED A LOT AND YOU WERE
ARTICULATE AND CLEAR.
IT LOOKS LIKE THE AUDIENCE
REALLY ENJOYED IT.
WE HAD MORE QUESTIONS THAT THAN
WE COULD HANDLE.
AND THAT IS NOT COMMON FOR THESE
SEMINARS.
LET'S LEAVE IT AT THAT.
THANK YOU FOR TAKING THE TIME TO
SPEND A COUPLE OF HOURS WITH US
THIS AFTERNOON.
AND WE'LL BE IN TOUCH.
THANK YOU FOR THE INVITATION.
THANK YOU.