By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Constantly talking isn’t necessarily communicating.”

-Charlie Kaufman, playwright/screenwriter

A Spanish-speaking patient calls her primary care health center, and talks with a triage nurse who speaks Spanish. She says her 5 year old son was seen in an emergency room in Southern California and told that her son has Monkeypox. She was given an appointment, the patient was roomed and the medical assistant recorded the chief complaint of Monkeypox.

It turns out, that the patient had infectious mononucleosis (this was what was diagnosed at the emergency room). How did this get misinterpreted?

The answer: Medical Spanglish!

The medical translation of Monkeypox is viruela del simio, but a more colloquial translation is viruela del mono. Viruela is the Spanish translation for Smallpox, so viruela del simio means Smallpox of the simians, and viruela del mono means “Smallpox of the monkeys.”

In contrast, the medical translation of infectious mononucleosis (or acute Epstein-Barr virus infection) is mononucleosis infecciosa or infeccion por el virus de Epstein-Barr. If the emergency physician had used one of these terms, there would not have been the confusion that ensued.

However, the emergency room physician spoke a little Spanish, and so mixed that Spanish with an English language shortened term for infectious mononucleosis: mono.

“Su hijo tiene el virus de mono”  which means to the parent: “Your child has the monkey virus,” which is pretty close to Monkeypox.

Early monkeypox presents with fever, fatigue, headache, and muscle aches, which is also the prodrome for COVID, infectious mononucleosis, influenza, and a hundred other illnesses so the lack of the characteristic rash is not sufficient to make a definitive diagnosis in the early stages.

Decades ago, Chevrolet had great difficulty selling a particular car model in Mexico and South America: the Nova. Nova in English is reminiscent of the French word for new, “nova” as in Nova Scotia. However in Spanish, “No va” means “no go” as in “the car that will not function.”

Providers with a little Spanish language capacity often have such miscommunications when they attempt to talk to their patients without a translator. They mix in English words, speaking Medical Spanglish.

Just as clinicians need to be precise and careful in their diagnostic process, this diagnostic information must be communicated to the patient in a way that they can fully understand, or the diagnostic process has failed. Communicating clearly with non-English speakers is a critical part of our professional responsibility as health care professionals.

For information on PHC provided video and telephonic interpreter services, see our website.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The search for a scapegoat is the easiest of all hunting expeditions.”
-Dwight D. Eisenhower

Part V in Series on Diagnostic Accuracy

Case Example: A 45 year old woman sends a secure electronic message to her primary care clinician, asking what she should do for her “heartburn.” Her PCP works a 3 day per week schedule at a chronically understaffed rural health center, and finally gets to the patient’s message at the end of a long day. The PCP does not ask any additional questions, but suggest the patient try OTC famotidine for a few days and call back if the “heartburn” is no better. Two days later, the PCP receives an electronically communicated consultation note from the local hospital, that the patient was admitted to the ICU in cardiogenic shock from a massive myocardial infarction. Glancing through the electronic health record, the clinician notes that the patient’s mother and father both died in their 40s of heart attacks.

This case of diagnostic error is certainly partly due to the PCP not performing an adequate assessment of the patient: not reviewing the electronic health record for background information, not asking additional questions to find out what the patient meant by “heartburn” or asking about red flag symptoms.

However, several system issues also contributed to the diagnostic errors: the overworked clinician, more prone to shortcuts to get through their day; the PCP’s reduced in-office schedule; the promotion of electronic communication to increase access to clinician; the lack of the PCP’s experience with rarer but more serious causes of “heartburn” because an emergency room/hospitalists sees all patients in the hospital.

The Institute of Medicine’s 2015 book “Improving Diagnosis in Health Care,” categorizes such system issues that contribute to diagnostic inaccuracy into five groups:

1. Organizational factors, such as schedules, staffing models, payer mix, and leadership.
2. Physical environment, including clinical ambiance, proximity to co-workers.
3. Tasks, which may compete for the attention of the clinician, like electronic medication refills, or which may not occur when they need to, like following up abnormal lab results.
4. Technologies and tools, such as the configuration of the electronic health record, and the use of electronic modalities for virtual care.
5. Diagnostic team members, including who is included on the team (adding a triage nurse for example), how communication occurs with the team, and the sense of responsibility team members feel to collaborate (in the case above, none of the physicians caring for the patient in the hospital called the PCP about the admission).

These same five factors contribute to clinician burnout and to health care inequities, so we as clinician leaders have a triple responsibility to spend our discretionary time working to steadily optimize this work system, the external environment that our clinicians work within. This is true for all clinician leaders, whether we work in primary care, specialty care, institutional settings like hospitals or skilled nursing facilities, at a health plan, or a government regulator.

At the same time, individual clinicians must continually strive to improve their own diagnostic processes, being aware of their own cognitive biases and short cuts, and reinforcing a sense of professional responsibility to achieve diagnostic excellence even with the shortcomings of the system we work in.