When language, health literacy, and miscommunication collide: tremors versus seizures.

COMMENTARY " The difference between the right word and the almost right word is the difference between lightning and the lightning bug. " —Mark Twain I f 77-year-old Guadalupe has never had a seizure in her life, why has she just been discharged from the hospital after a seizure medication overdose? To answer that question, let us retrace the steps of an elderly Spanish-speaking patient through her clinical encounters at a family medicine residency. Reviewing the chain of events that unfolded, we explore vital communication challenges— language barriers, limited health literacy, and disjointed inter-provider communication that are encountered daily in clinical settings. The combination of being unable to communicate symptoms, misunderstanding medication instructions , and having fragmented primary care culminated in this patient's super-therapeutic doses of seizure medication and hospitalization. Guadalupe's experience may compel providers to examine the value of effective communication in patient care, both in medical education and practice. Guadalupe is one of an estimated 47 million people in the United States who speak a language other than English at home. 1 Many are limited English proficient (LEP) and have a limited ability to read, speak, write, or understand English. As a Latina, Guadalupe is also part of the largest and fastest growing minority group in the United States. In California, one in five Latinos speaks Spanish at home, 2 yet one study found that only 26% of Califor-nia's primary care doctors report Spanish fluency. 3 Roughly 70% of California Latinos (9 million) may require an interpreter when seeking medical care unless their doctor speaks Spanish fluently. 1 LEP status can lead to delays in patient care, poor adherence to treatment regimens, excess use of emergency rooms, and higher health care costs. 4 The Health and Human Services Guidelines state that LEP patients should have access to professional interpreters or competent bilingual staff—and family members should not be used except at the pa-tient's request. 5 But the reality is that many physicians rely on ad hoc interpreters (medical assistants, receptionists, janitors, family members) despite evidence that this can lead to errors and poor outcomes. This is especially a problem in academic settings where residents sometimes try just " getting by. " Common reasons residents decide not to use interpreters include time constraints, inconvenience, and no perceived value in clinical decision making. 6 Guadalupe's resident doctor did not speak Spanish and did not document use of an interpreter. Guadalupe …