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BACKGROUND: Limited English proficiency (LEP) is common among hospitalized patients and may impact care. We synthesized the literature comparing clinical outcomes after in-hospital care for English-proficient(EP) versus LEP patients. METHODS: This systematic review searched PubMed, Embase, and Web of Science from database inception through June 7, 2020, to identify research investigating clinical outcomes in patients receiving hospital-based care (in the emergency department, inpatient ward, surgical/procedural suite, or intensive care unit) that compared patients with LEP to an EP group. We assessed mortality, length of stay (LOS), readmissions/revisits, and complications. Study quality was evaluated using the Newcastle-Ottawa Scale. RESULTS: Twenty-six studies met eligibility criteria. Study settings and populations were heterogeneous. Determination of primary language varied; a majority of studies (16/26) used patient self-report directly or via hospital records. Of 16 studies examining LEP and allcause mortality, 13 found no significant association. Of 17 studies measuring LOS, 9 found no difference, 4 found longer LOS, 3 found shorter LOS, and 1 had mixed LOS results among patients with LEP. Several investigations suggested that LOS differences may be mediated at the hospital level. Nine studies evaluated inpatient readmissions. Among patients with LEP, there was evidence for increased readmissions in the setting of chronic medical conditions such as heart failure, but no evidence for increased readmissions among cohorts undergoing surgeries/procedures or with acute medical conditions. Five studies evaluated complications or harm related to a hospitalization, and no differences were found between language groups. DISCUSSION: The research community lacks a standardized definition of LEP. Most studies did not find an association between English proficiency and mortality or complications. LOS findings were mixed and may be influenced at the hospital level. Differences in readmissions by language were concentrated in chronic medical conditions. Given the paucity of studies examining LEP populations, additional research is imperative.

The life-threatening risk of the COVID-19 pandemic has caused considerable mental health problems including anxiety, depression, and post-traumatic stress disorder in healthcare workers. 1,2 Although people respond to adversity and stress in various ways, there is evidence that people can positively change their perspectives and experience personal growth as a result of major life crisis or traumatic events. This process is known as post-traumatic growth (PTG) and was first described by Tedeschi and Calhoun in 1996. 3 PTG is characterized by positive adjustments that occur following severe traumatic experiences and includes five major aspects: forging stronger relationships with others, increased perception of personal strength, willingness to embrace new possibilities, deeper appreciation of life, and increased spirituality. 3 Since the COVID-19 pandemic, researchers have refocused their lens on assessing the PTG of front-line health care workers such as doctors and nurses. However, research to date has not investigated PTG in general surgery residents during the COVID-19 pandemic. As such, in December of 2020 we conducted an IRB-approved, multi-center survey of general surgery residents from four academic medical centers in Boston, MA. The survey consisted of 23-questions, including a modified Post-Traumatic Growth Inventory (PTGI) (supplement). 4 A total of 75 of 172 surveys were completed, for an overall response rate of 43.6%. Both female (46.7%) and male (53.3%) residents participated. The most positive COVID-19 related change reported by the surveyed general surgery residents was the feeling that they can rely on people in times of trouble, followed by increased compassion for others, greater sense of personal resilience, greater appreciation for their own life's value, greater sense of closeness with others and increased relationship efforts, changed priorities about what is important in life, increased willingness to express emotions and try to change situations that they are unsatisfied with, increased appreciation of each day, and appreciation of new opportunities (Fig. 1). Interestingly, our study showed that female residents reported greater growth than male residents in all components of the PTGI.