In the emergency setting, communication is essential to provide efficient and effective patient care especially given the context of high acuity, limited availability of patient history, and high patient volumes. Prior studies indicate that communication challenges in the Emergency Department (ED) can have a negative impact on quality and safety of care and the patient’s subjective experience (Slade, 2011). An Australian emergency communication study cited that the main cause of critical incidents in their hospital system, namely adverse events that resulted in patient harm, was poor and inadequate communication between clinicians and patients (Slade, 2008). Good communication is the foundation of great clinical care in the emergency department. Physician communication is positively correlated with patient adherence to treatment. One meta-analysis indicated that there was a 19% increased risk of non-adherence with patients of physicians who communicated poorly (Haskard Zolnierek, 2018). Additionally, good clinician-patient communication in the emergency department during life threatening cardiac events has been associated with decreased subsequent post-traumatic stress reactions (Chang, 2015).
In India, linguistic alignment of providers and patients is even more complex due to the immense language diversity that exists within the country. There are over 22 official languages that are spread over the regions of India, and at least 122 different spoken languages (Narayan, 2013). While many of these languages are regional, migration patterns continue to contribute to a diversity of language in any local setting. Similar to other countries, a physician in training in India may grow up in one region, obtain their medical degree in another, and complete their specialty training in yet again another region. Unique to India, however, each of these regions is likely to have a different primary spoken language. Therefore, physicians in training in India are not only learning medicine, they are often learning the languages of their patients along the way. These factors result in a multilingual health care environment where ensuring language alignment presents a challenge.
Language barriers in the health care setting are neither a novel nor a foreign problem. In the United States individuals with limited English proficiency are documented to have worse healthcare access and report lower quality of care when compared to individuals proficient in English (Berdahl, 2018). Additionally, language barriers have been reported as one of the greatest causes of health care disparities in a cross-sectional study of pediatric emergency departments (Fields, 2016). Effects of language barriers can range from misunderstandings to compromising quality of care (Schlemmer, 2006). An in-depth language and culture study performed at a pediatric hospital in South Africa investigated the communication between English speaking doctors and Xhosa speaking patients and parents. The study documented that even when physicians and parents were using the same words, those words held different meanings for each group. This led to what they concluded to be a clinically significant discordance in understanding (Levin, 2006). This begins to unravel the cultural complexities that are entwined with language diversity.
Communication in the health care setting is not only stymied by language diversity, but a host of barriers that include health literacy. An extensive 2011 systematic review of the literature reported the low health literacy is associated with poorer health outcomes and poorer use of healthcare services (Berkman, 2011). A recent study sampling English-speaking and Spanish-speaking ED patients to investigate health literacy using language congruent tools found that 93% of Spanish-speaking patients sampled had limited health literacy (Sarangarm, 2017). Self-reported reading ability and years of school completed have been shown to be adequate predictors of health literacy (Brice, 2008).
This study was undertaken to better understand the challenges to effective communication in the ED in India, including but not limited to language. The field of Emergency Medicine is in its infancy in India. Emergency Medicine was recognized as an independent specialty by the Indian government in 2009. Pre-hospital care and trauma responses have been described as “disorganized and inadequate” by India’s own emergency experts (Wesson, 2017). Government sponsored EM training programs only produce 48 emergency physicians each year to serve a population of over 1.3 billion. To contribute to closing this gap in education and training, some private hospitals in India have partnered with US academic institutions, including ours, to provide post-graduate emergency medicine training for physicians. Our department has affiliations at numerous hospitals across India (Douglass, 2015). A previous study and first-hand experience have revealed significant gaps in language and communication in Indian EDs. This mixed-methods study aims to examine communication issues experienced by health care providers at six hospitals in India.