Case Presentation: A 67 yo blind man was admitted with confusion due to cholangitis. The patient was unable to participate on the day of admission in the interview due to his confusion. His family reported he had not drank alcohol for 3 months. On hospital day 2, the patient was able follow simple directions, but the provider noted they were unable to understand him. MRCP was negative, and the team felt that patient’s presentation were more consistent with decompensated liver cirrhosis secondary to alcohol use. On day 3, the patient was able to speak and his provider noted “He doesn’t feel good… finds it difficult to expand on that… limited willingness to interact with me.” He continued treatment for cholangitis and decompensated cirrhosis presumed due to alcohol use.On day 6, the hospitalist asked his preferred language and he indicated Navajo. Through an interpreter the patient said, “I don’t understand what people are saying to me. They speak too fast.” He had not had an interpreter offered to him yet that admission. His preferred language was changed in the EMR and on the shift hand-off tool.On day 9, it was found that he was still being spoken to in English. The interpreter service had not been contacted in more than 48 hours. The providers, the patient’s charge and floor nurses, the patient’s family, and the patient were educated on the patient’s language preference, how to access interpreters, and a request to the patient and his family to advocate for utilizing interpreters at all times. On chart review, in 29 days spread over 5 admissions and 4 outpatient visits, English was used to communication with the patient nearly each time. Communication difficulties were noted frequently, such as “poor historian,” “very difficult historian,” “only a fair historian,” “incredibly poor historian,” “I have explained as best as I can with his visual disturbances about the process for [procedure]… his questions are only fair, but he seems to demonstrate understanding,” and “… he thought that we had offered to remove his liver to prevent him from having stones like this again however I did clarify with him that we were discussing removing his gallbladder which is adjacent to his liver not his actual liver.”

Discussion: This vignette highlights challenges in recognizing when patients do not understand their care and when they have limited English proficiency (LEP). Approximately 78% of people in the US speak English, and only 170,000 speak Navajo. In this case, there were widespread misunderstandings.The Civil Rights Act of 1964 requires hospitals provide interpreter access, but still many patients do not. There are many reasons hospitalized patients with LEP have increased mortality, and hospitalists should engage leadership to ensure easy identification of patients’ preferred languages and easy access to interpreter services. Electronic medical record alerts and visual prompts may help identify patients who would benefit from interpreter services.

Conclusions: Hospitalists commonly care for patients with LEP, and there are negative consequences to patients when they don’t receive care in a language they understand. Hospital medicine groups should collaborate with senior leadership and with interpreter services to develop robust systems to identify patients’ preferred languages, have adequate and accessible trained interpreters, and to facilitate hospitalists and other clinicians using interpreters.