To the Editor: Bakhtiar et al1 have reported that several underserved populations encounter inequities in accessing telemedicine; however, it is important to not overlook unusual obstacles experienced specifically by patients with limited English proficiency (LEP). Patients with LEP already face significant challenges, such as higher rates of complications, worse outcomes, and decreased satisfaction, when navigating through the health care system.2, 3, 4 Language concordance among Spanish-speaking patients and providers has been associated with a lower incidence of medical errors, confusion, and frustration.5 Language concordance should be considered when delivering health care through telemedicine.
While telemedicine has allowed for continued care access during the pandemic, its widespread use may increase the disparities experienced by patients with LEP, particularly in dermatology. Given the visual nature of the dermatology examination, the examination of the skin has inescapably pivoted to store-and-forward photography, which requires not only extra infrastructure but also some degree of technology literacy. Patients must be able to download hospital-approved telemedicine software, navigate the online medical record, and follow instructions on submitting quality skin photographs, which is difficult when there is a language discordance. In our hospital, we have seen higher rates of missed dermatology virtual visits in Spanish-speaking patients compared with English-speaking patients, and there have been delays in connecting interpreter services during virtual visits due to added scheduling logistics. Outside vendors offering telemedicine software do not consistently offer interpreter services and are often not integrated with the online medical record. Physicians and hospital organizations must address this language discordance to better serve marginalized populations.
We offer potential solutions that may mitigate this issue (Table I ). Communication channels should accommodate patients with LEP. First, verbal communication must be adapted to the patient's preferred language. Administrators should inquire all patients whether they need an interpreter as English-speaking family members may make appointments on behalf of the patient but may not accompany the patient to the visit itself. Phone reminders and instructions should always be provided in the patient's preferred language. Further, in the pediatric setting, interpreters should still be offered when the caregiver has LEP, even when the child has English fluency. Second, written communication should be available in the patient's primary spoken language. This includes modifying the patient-facing online medical record and emails such as appointment reminders and instructions on photo-taking and uploading. Other methods of delivering written appointment information other than email or patient portals, such as text message, should also be examined. We must also consider the level of literacy and explore the uses of visual tutorials including video or infographics that could be easily understood regardless of language.
Table I.
Potential communication barriers to telemedicine care for patients with limited English proficiency and proposed best practices
| Type of communication | Barriers | Proposed best practices |
|---|---|---|
| Written communication | Telemedicine has led to increased use of written communication. The default language for online medical record, emails, instructions for store-and-forward photo-taking and uploading, and text messages is English. | Adapt all forms of written communication to patient preferred language |
| Varying levels of written literacy | Consider visual tutorials such as video or infographics | |
| Verbal communication | Patient preferred language may not be accurate in online medical records | Ask all patients and caregivers whether they need interpreters |
| English-speaking family members may make appointments on behalf of the patient | ||
| Caregivers with limited English proficiency with children who are fluent in English | ||
| Default language for phone call reminders and instructions is English | Deliver this information in patient preferred language |
These recommendations may be helpful but require access to resources. We recognize that some dermatologists, including those in academic centers, work in underserved resource-limited areas and care for the exact communities which may benefit most from these interventions. More funding at state and national levels may be necessary to ensure language-concordant health care is delivered appropriately and equitably. Telemedicine services in dermatology may disproportionately affect patients with LEP. It is crucial that new strategies are implemented in order to prevent the exacerbation of these disparities.
Conflicts of interest
None disclosed.
Footnotes
Funding sources: None.
IRB approval status: Not applicable.
Reprints not available from the authors.
References
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