There is more than one way for a language-related misunderstanding to occur between a patient and a healthcare provider, according to articles in two recent issues of the New England Journal of Medicine.

One of the ways, becoming more familiar all the time in many parts of the country, is a mismatch of language backgrounds—the doctor speaks and understands only English; the patient speaks and understands only Spanish or some other language. That may lead to humorous exchanges, or to tragedy—the author of one report cites a case in which a Spanish-language mother was forced to relinquish custody of her children on suspicion of abuse after a nurse and a social worker misunderstood the mother’s assertion that her two-year-old had "hit herself" when falling off a tricycle.

And the other way, which is much harder to spot and which can’t be remedied by an interpreter, is real, actual illiteracy—the condition in which a patient cannot read or write, and has grown to adulthood concealing that fact in a number of ways.

In cases of language mismatch, it’s important to keep in mind that the Census Bureau reports that almost 50 million Americans—19 percent of the U.S. population—has limited English proficiency and speaks a language other than English at home. Yet, given those formidable numbers (which are much higher in places like California and Miami, Florida), many patients who need interpreters have no access to them. According to one study, no interpreter was used in 46 percent of emergency department cases involving patients with limited English. Only 23 percent of U.S. teaching hospitals provide any language training, and those that do make it optional.

Language barriers can have serious effects. According to the researchers, patients with language use-and-understanding problems are less likely than others to have a usual source of medical care, receive fewer preventive services, and have increased risk of nonadherence to medication. Those with psychiatric conditions are more likely than others to receive a diagnosis of severe pathology and are more likely to leave the hospital against medical advice. Children with asthma have increased risk of intubation. Patients are less likely to return for follow-up after emergency room visits, and though greater resources are used in their care, have lower levels of patient satisfaction.

Although the U.S. Office for Civil Rights in 1998 issued a memorandum stating that denial or delay of medical care because of language barriers constitutes illegal discrimination under Title VI of the Civil Rights Act, additional guidelines issued in 2003 seem to allow healthcare facilities to opt out of providing language services if their costs are too burdensome. The 2003 guidance also says that use of "ad hoc" interpreters—such as family members, friends, untrained members of the support staff, and strangers found in the waiting room—"may be appropriate."

It’s pretty hard not to notice if a patient cannot speak or understand the doctor’s language, but another language problem—illiteracy--can go undiagnosed for a considerable period of time, researchers say, with the treating personnel puzzled by a patient’s behavior, often including nonadherence to prescription dosages and failure to keep return appointments.

The problem of "blindness to illiteracy" is common, says the National Assessment of Adult Literacy, a survey conducted by the National Center for Education Statistics, which reports that an estimated 14 percent of adults in the United States have "below-basic" levels of prose literacy, defined as the ability to use printed and written information to function in society. Twelve percent of adults are also estimated to have below-basic "document literacy," meaning they can’t read and understand drug or food labels.

Says researcher Dr. Erin Marcus, "There’s also a growing body of research on health literacy, the ability to comprehend and use medical information." Patients with reading problems may avoid doctors’ offices and clinics because they are intimidated by paperwork, but emergency rooms may be more user-friendly because there, someone asks questions and fills out the forms for you.

Barry Weiss, a professor of family and community medicine at the University of Arizona, advocates routine screening for illiteracy as a new vital sign, though many doctors oppose such an idea as opening a Pandora’s box of social and other problems that they haven’t been trained to handle. In the meantime, doctors may think they’ve explained medications clearly and may have no clue that an illiterate patient has no way of reading the prescription label.

"These days, I think twice whenever I explain anything to a patient or jot down instructions on a pad of paper," said one doctor.

An article, "Language Barriers to Health Care in the United States," appeared in the July 20, 2006 issue of the New England Journal of Medicine. An article, "The Silent Epidemic—The Health Effects of Illiteracy," was published in the New England Journal of Medicine July 27, 2006.

See also: Children of Immigrants and Refugees: What the research tells us, at http://www.healthinschools.org/cac/immigrantfs.pdf, and Caring Across Communities at http://www.healthinschools.org/cac.asp.