NEW YORK (MainStreet) — An estimated 12 million people Americans -- 1 in 20 -- are misdiagnosed every year, and half of those errors are potentially harmful, according to a 2014 online report in the journal BMJ Quality & Safety. These erroneous diagnoses were made in outpatient clinics, where problems are rarely reported, and the results are costly.

To date, little has been reported on misdiagnoses due to cultural and racial differences, including language differences, cultural misinterpretations, and patient distrust, among other factors.

There are many people in the U.S. who have limited English proficiency, according to Gail Price-Wise, president of the Florida Center for Cultural Competence. They speak and understand English, and may appear to be sufficiently fluent, but may not be able explain their symptoms to a health care provider or understand medical terms, Price-Wise says. If it becomes apparent to the provider, he or she may use a family member or friend to interpret, which, rather than remedy the situation, can cause more problems that may go unnoticed by the clinician, she says.

Interpreting language is complex, and many things can get in the way of effective communications, says Price-Wise. First, many people don’t know much about physiology and anatomy. It’s difficult to communicate what’s not well understood by the patient or interpreter. Second, the interpreter must be able to remember what the patient said, and the patient may have taken quite a bit of time to describe his or her problems. Third, the interpreter may give a summary of what he or she thought was important and, unwittingly, leave out clinically-relevant information; alternatively, the interpreter may decide not to relay information, because it’s embarrassing, or the interpreter may not relay information from the doctor to the patient to avoid upsetting the patient. Untrained interpreters may also add their own opinions. These errors and omissions can impact a diagnosis or treatment plan, Price-Wise notes. Trained interpreters, on the other hand, have the same conversation as if they spoke the same language, Price-Wise says.

Further complicating communications are false cognates, words that sound alike in two languages but have different meanings. For example, “embarrasada” in Spanish means pregnant, not “embarrassed.”

Price-Wise also broached a case in which a teenager who arrived in the emergency room was treated for a drug overdose, because his family believed he had food poisoning, “intoxicado,” in Spanish. In fact, he had a brain hemorrhage that was overlooked as a result of the misinterpretation of a word that sounded like “intoxicated.” He was left a quadriplegic.

Cultural misunderstandings have, to some degree, been studied in psychiatric settings.

“Our work suggests that, in African Americans compared with both Latino and non-Latino whites, clinicians excessively weight psychotic symptoms…in African-Americans as the expense of mood and anxiety symptoms during clinical assessments, leading to an erroneous conclusion of schizophrenia in the former,” says Stephen M. Strakowski, a professor of psychiatry and behavioral neuroscience, psychology, and biomedical engineering at the University of Cincinnati College of Medicine.

Strakowski points out that hallucinations, delusions, and thought disorders are not disease specific. They can occur as a result of a brain tumor, stroke, or infection, among other non-psychiatric conditions, or drug abuse, depression, post traumatic stress disorder (PTSD), bipolar disorder, or schizophrenia, among others.

“Schizophrenia is not supposed to be diagnosed until other causes of psychosis are ruled out,” Strakowski says.

Strakowski says the reasons for the overweighting are not known, but he thinks it could be that clinicians are misinterpreting distrust of doctors among African Americans as paranoia, or clinicians may be missing the symptoms of PTSD, which, Strakowski says, can mimic psychotic symptoms. He also thinks it’s possible that it could result from a delay among African Americans in getting treatment so that they are more ill on presentation. Or, it may be due to a failure among clinicians to understand the cultural differences in idioms of distress with regard to mood symptoms.

“There is no evidence of overt systematic bigotry, per se, and the race of the clinician doesn't seem to particularly impact the problem,” Strakowski says.

—Written by S.Z. Berg for MainStreet