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A shared language, particularly in treatment settings, is of crucial importance to effective communication between medical professionals and their patients. In order for clinicians to obtain an accurate and complete history, patients must convey nuanced information describing relevant history, the medical problem itself, and the context in which it arose through mutual, intelligible means of communication ^[1]. In recent decades, the U.S. has seen a revival of linguistic diversity en masse (with the largest portion of non-English speakers being Spanish speakers) .

Conceivably, this demographic shift has resulted in language barriers that have affected non-English speaking patients’ quality of healthcare, access to care, and health status/outcomes ^[3]. According to a 2016 Brookings Institution report, nearly one in ten Americans aged 16 to 64 is considered limited- or non-English proficient ^[4]. Despite the fact that U.S. is considered by many to be a multicultural country, the healthcare system is primarily geared towards English-speakers ^[3]. Research demonstrates that when a patient does not speak the same language as their medical provider, various detrimental effects to their healthcare may occur ^{[1, 3]}. For instance, lack of comprehension in a discussion of relevant medical education and treatment information can lead to poor patient satisfaction, low treatment-plan compliance, and an underutilization of services ^[3]. Diminished access to preventive care and/or primary care has also been found to be common in populations with low English-fluency skills ^[5]. What’s more, there may be serious legal and financial repercussions if medical providers fail to provide adequate medical services to patients with limited English proficiency.Perhaps the most significant barriers in overcoming language disparities in clinical settings is the dearth of skilled, certified medical interpreters ^{[1, 3, 5]}. Research on the use of translators in emergency room settings revealed that no interpreter was used in nearly half of cases involving a non-English speaking patient ^[6]. Consequently, non-English speaking patients must often rely on bilingual family members and/or healthcare staff who do not have formal training in medical translation services, which may represent potential ethical breaches ^{[1, 3]}. Furthermore, crucial, nuanced details can become lost in mistranslation; and misinterpretation has been shown to precipitate medical and logistical catastrophes. In one case, hospital personnel translating for a nurse practitioner instructed the mother of a seven-year-old to administer oral amoxicillin in her daughter’s ears ^[5]. In another, a resident who relied on partial Spanish skills mistranslated a mother’s description of her two-year-old’s tricycle accident (the literal translation being that she “hit herself” while falling off) and perceived the fracture to have been caused by abuse; the attending contacted social services—without an interpreter—had the mother sign away custody of her two children ^[5]. Evidently, the consequences of language barriers may be severe and not limited to medical outcomes.

Furthermore, language barriers—even when assuaged by the use of interpreters—may represent complex challenges in effective patient-provider communication dynamics ^[5]. For instance, the delivery of subtle non-verbal cues indicative of relevant information may become lost in translation ^[1]. Additionally, a lack of sensitivity towards cross-cultural differences on all sides may hinder the quality and efficacy of healthcare services ^{[1, 3]}. Those who study this issue closely have proposed the notion that all payers be required to reimburse providers for medically skilled interpreter services ^[5]. Without question, the mandated provision of satisfactory language services would significantly aid in producing improved patient resource use, satisfaction, communication, outcomes, and patient safety .

Partida, Yolanda. “Language Barriers and the Patient Encounter.” Journal of Ethics | American Medical Association. American Medical Association, August 1, 2007. https://journalofethics.ama-assn.org/article/language-barriers-and-patient-encounter/2007-08.

Rumbaut, Rubén G, and Douglas S Massey. “Immigration and Language Diversity in the United States.” Daedalus. U.S. National Library of Medicine, 2013. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4092008/.

Timmins, Caraway L. “The Impact of Language Barriers on the Health Care of Latinos in the United States: a Review of the Literature and Guidelines for Practice.” Journal of Midwifery & Womens Health 47, no. 2 (2002): 80–96. https://doi.org/10.1016/s1526-9523(02)00218-0.

Wilson, Jill H. “Investing in English Skills: The Limited English Proficient Workforce in U.S. Metropolitan Areas.” Brookings. Brookings, August 24, 2016.

Flores, Glenn. “Language Barriers to Health Care in the United States.” New England Journal of Medicine 355, no. 3 (2006): 229–31. https://doi.org/10.1056/nejmp058316.

Baker, D W, R M Parker, M V Williams, W C Coates, and K Pitkin. “Use and Effectiveness of Interpreters in an Emergency Department.” JAMA. U.S. National Library of Medicine, March 13, 1996. https://www.ncbi.nlm.nih.gov/pubmed/8598595.

Meuter, Renata F. I., Cindy Gallois, Norman S. Segalowitz, Andrew G. Ryder, and Julia Hocking. “Overcoming Language Barriers in Healthcare: A Protocol for Investigating Safe and Effective Communication When Patients or Clinicians Use a Second Language.” BMC Health Services Research. BioMed Central, September 10, 2015. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-015-1024-8.

Evidence-based clinical practice is an approach to health care in which professionals use the best evidence possible—i.e., scientific data and other appropriate information—to make clinical decisions about patient care.¹ Evidence-based practice (EBP) has been on the rise for over 20 years,² and in health care in particular, it involves the combination of scientific evidence, clinical expertise and individual patient needs.¹ EBP is particularly important because it allows health professionals to use data from systematic research in their everyday practices, thus giving individualized purpose to broad studies and keeping health care standard across clinicians.³

EBP not only applies to individual or group health care practices, but also to organizational and national guidelines on medical care. For one, the Japanese Society of Gastroenterology published the Evidence-based Clinical Practice Guidelines for GERD in 2009, and then updated these guidelines in 2015 based on research in GERD epidemiology, pathophysiology and treatment during this period.⁴ These new data informed the society’s suggested practices, including those regarding treatment with proton pump inhibitors (PPIs). Later, in 2017, Farrell et al. used a systematic review of PPI trials and side effects to recommend reducing or stopping treatment with PPIs after a short period of time.⁵ Clearly, the case of gastroenterology’s fast-pace updates to standard practice guidelines demonstrates the influence that systematic evidence can have on individual patient care.

Meanwhile, evaluations of clinical practice quality—aside from simply suggestions or guidelines—are also influenced by scientific evidence. The Centers for Medicare & Medicaid Services (CMS) lists evidence-based care as one of its core competencies in its initiatives for quality health care.⁶ Thus, health professionals’ quality of patient care is assessed based on their individual patients’ outcomes as well as on their ability to integrate scientific evidence into their practices. Indeed, EBP and quality improvement efforts are often linked within health care;⁷ EBP is cited as a critical part of quality improvement⁸ and as a mechanism through which health professionals can improve quality of care.

Nonetheless, EBP has faced challenges throughout the years of its popularity. For example, Hisham et al.’s interviews of various primary care doctors revealed that—despite being aware of and having a positive attitude toward EBP—participants cited heavy workload and lack of training as barriers to implementing EBP in their own clinical practices.¹⁰ Additionally, some doctors were concerned that EBP compromised personalized patient care and did not consider an individual physician’s clinical experience. Meanwhile, De Smedt et al. found that while physicians, nurses and paramedics used forums such as the Internet and textbooks to gather evidence, they claimed that lack of time, the overwhelming mass of literature and difficulties integrating evidence into practice were the most common barriers to EBP.¹¹ Overall, EBP is not universally acknowledged as a panacea, and its general acceptance may not necessarily lead to EBP-friendly workplaces.

In sum, EBP can serve as a method for systematic research to make its way into the everyday lives of patients and health care professionals. EBP helps medicine keep pace with clinical evidence and allows professional organizations to standardize practice.¹² Future researchers must explore if EBP is feasible given health professionals’ heavy workloads, if it encourages personalized solutions for patients and, ultimately, if it can lead to improved quality of health care.

1.         McKibbon KA. Evidence-based practice. Bulletin of the Medical Library Association. 1998;86(3):396–401.

2.         Guyatt G, Cairns J, Churchill D, et al. Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine. JAMA. 1992;268(17):2420–2425.

3.         Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: What it is and what it isn’t. BMJ. 1996;312(7023):71–72.

4.         Iwakiri K, Kinoshita Y, Habu Y, et al. Evidence-based clinical practice guidelines for gastroesophageal reflux disease 2015. Journal of Gastroenterology. 2016;51(8):751-767.

5.         Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors. Evidence-based clinical practice guideline. 2017;63(5):354-364.

6.         Centers for Medicare & Medicaid Services. Quality Initiatives: General Information. April 2018; https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/index.html.

7.         Banerjee A, Stanton E, Lemer C, Marshall M. What can quality improvement learn from evidence-based medicine? Journal of the Royal Society of Medicine. 2012;105(2):55–59.

8.         Solomons NM, Spross JA. Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: an integrative review. Journal of nursing management. 2011;19(1):109–120.

9.         Grimshaw J, Eccles M, Thomas R, et al. Toward Evidence-Based Quality Improvement. Journal of General Internal Medicine. 2006;21(S2):S14–S20.

10.       Hisham R, Ng CJ, Liew SM, Hamzah N, Ho GJ. Why is there variation in the practice of evidence-based medicine in primary care? A qualitative study. BMJ Open. 2016;6(3):e010565.

11.       De Smedt A, Buyl R, Nyssen M. Evidence-based practice in primary health care. Studies in Health Technology and Informatics. 2006;124:651–656.

12.       Masic I, Miokovic M, Muhamedagic B. Evidence based medicine – New approaches and challenges. Acta Informatica Medica: Journal of Academy of Medical Sciences of Bosnia and Herzegovina. 2008;16(4):219–225.