Language Is Not A Barrier—It Is An Opportunity To Improve Health Equity Through Education

Health systems have a lot to gain from clinician education around effective communication with non-English-speaking patients. In 2013, more than 61 million people in the US reported speaking a non-English language at home, of which approximately 4 out of 10 reported limited English proficiency (LEP); that number rose to nearly 66 million in 2019. Despite the linguistic diversity of the US, health professions schools typically only teach clinicians to communicate with patients in English, resulting in significant gaps in providing quality health care to the growing LEP population.

Research has shown that language-discordant encounters—or, in other words, encounters where the patient and clinician do not speak the same language—result in worse health outcomes, reduced access to health information, and decreased satisfaction with care. Conversely, language-concordant care improves health outcomes for individuals with LEP. An objective-in-development of the Healthy People 2030 initiative of the Department of Health and Human Services is to “increase the proportion of adults with LEP who say their providers explain things clearly.”

How do we work toward these goals of improving health care access and communication for all patients, regardless of language? One important yet overlooked opportunity is in how we educate clinicians.

Medical education represents a critical opportunity to apply language-appropriate health policies that support health equity, health care quality, and efficiency by:

1. preparing all clinicians to identify patients with non-English language needs, build a positive patient-clinician relationship in the setting of language discordance, and navigate language assistance services; and
2. teaching clinicians to communicate independently with linguistic groups to whom they wish to provide direct care.

Current Health Policy Falls Short On Language

While US law has a non-discrimination policy related to health care services that explicitly protects the rights of linguistically diverse patients, how such a policy can best be implemented is not as clear. The Culturally and Linguistically Appropriate Services (CLAS) standards provide guidelines for implementing language-appropriate care, yet research shows that many hospitals do not comply with federal regulations. CLAS standards recommend two ways to provide language-appropriate care: a qualified bilingual provider and language assistance.

Most of the work to improve language-appropriate care has focused on language assistance and improving interpreter services. Research has highlighted the benefits of working with medical interpreters, including decreased readmission rates, increased health care use, and improved patient outcomes. However, multifaceted challenges to adequate implementation of medical interpreting guidelines still remain, such as the frequent use of ad hoc interpreters (for example, family members or untrained staff), underuse of professional medical interpreters despite recognized need, and limited data collection, including a lack of documentation of clinician language skills. One study analyzing malpractice claims in four states found that 2.5 percent of all claims were attributable to failure to provide competent language interpretation, providing evidence of the high costs—financial and, most importantly, related to patient harm—of inappropriate language use in medical care. Of all factors identified as barriers to providing language-appropriate care, lack of clinician knowledge of why, how, and when to access professional medical interpreters has been found to be most significant.

Despite existing policies and guidelines intended to ensure adequate communication for LEP groups via language assistance, language continues to be viewed as a “barrier” to care, leading both multilingual and monolingual clinicians to feel frustrated and in some cases over-burdened in caring for patients who speak limited English. Medical language education represents a largely untapped opportunity to improve health equity, but lack of clarity in health policies leads to confusion in the qualifications, training, and assessment of bilingual providers. In the absence of clear federal policies, the following three suboptimal approaches are used commonly by health care centers:

The Free-For-All Approach

Clinicians are sometimes asked about language skills upon hiring, but questions often lack guidance on what constitutes the ability to speak a language in the context of clinical responsibilities. This approach endangers patient safety when clinicians use limited skills to “get by” in medical encounters with LEP patients. Policies may differ for trainees who may not be asked about language skills at all. Medical students with some bilingual skills report being asked frequently to serve as medical interpreters to assist during clinical encounters with non-English speaking patients. Without clear policies, trainees may feel forced to agree to “help” even if unprepared or uncomfortable.

The One-Size-Fits-All Approach

Some medical centers apply a one-size-fits-all approach, such that all clinicians are required to involve professional interpreters in caring for non-English-speaking patients, regardless of the clinician’s language skills. This approach is inefficient and may involve unnecessary expenditures. While working with certified medical interpreters is superior to working with an untrained interpreter or “getting by” with limited skills and no interpreter, clinical outcomes are still superior with patient-clinician language concordance. One study estimated that medical encounters involving interpreters, including professional interpreters, had an average of 31 communication errors. Clinicians with competent bilingual skills may feel unsupported and undervalued since their linguistic skills are being unaccounted for in policy making.

Training Clinicians As Interpreters

Some hospitals choose to increase their pool of medical interpreters by training clinical staff as interpreters. This strategy is not ideal for several reasons. First, interpreter training is intended for medical interpreters, not for bilingual clinicians who provide direct patient care in a given language. Conflating the two carries the risks that neither goal will be adequately achieved and that bilingual providers will be frequently pulled from their clinical duties to serve as an interpreter. Clinicians serving as interpreters are particularly at risk for committing a common interpreting error called editorialization since their clinical training prepares them to voice medical recommendations—yet medical interpreters are supposed to remain neutral while interpreting. Existing standardized processes for medical interpreting certification (currently offered by two accredited organizations: the Certification Commission for Healthcare Interpreters and the National Board of Certification for Medical Interpreters) involves 40 hours of training, a code of ethics, and an exam. This rigorous interpreter training is not meant to address clinicians’ job responsibilities in providing direct patient care. Some hospitals provide badges to specifically identify clinicians trained as interpreters without accounting for the extra responsibilities that typically accompany such a label in the clinician’s schedule or salary.

In place of these approaches, we propose health policy recommendations that capitalize on medical language education as a prime opportunity to improve the care of LEP populations.

Recommendations For Language-Appropriate Health Policy Aligned With Education

Like other medical skills, clinician language skills are not static and need to be taught, evaluated, and progressively re-assessed. Augmenting the qualified bilingual provider workforce to reach the Healthy People 2030 Health Communication Objective and reduce inequities for patients with LEP should involve the following health policy adjustments:

Specify The Qualifications For A Clinician To Become Identified As A Qualified Bilingual Provider

Individuals should not be left to decide for themselves how to use their language skills without guidance or support. Similar to the process of certifying medical interpreters, medical education systems should develop a systematic, standardized approach to medical language (for example, medical Spanish) skills acquisition and assessment such that clinicians can have the opportunity to become qualified bilingual providers and to feel confident and supported in using their confirmed language skills in patient care. While some institutions develop their own testing system or use commercially available tests to evaluate clinicians’ language skills, additional research is needed to ensure that assessment methodologies align with clinicians’ responsibilities.

Given that more than three-quarters of US-born individuals with LEP speak Spanish and that about two-thirds of immigrants with LEP speak Spanish, most US medical schools offer some form of medical Spanish education. However, curricula vary widely and include student-run clubs without faculty supervision. Programs face challenges including a lack of trained educators or institutional support, as their educational efforts are often viewed as extraneous. Clearly defining the criteria for qualified bilingual providers and linking medical language educational objectives to health policy goals are necessary steps to ensure an institutional investment in medical language training for clinicians.

Develop Level-Based Training Requirements For Clinicians Who Wish To Become Qualified Bilingual Providers

Health policies guiding the use of clinician language skills should not be one size fits all. Clinicians with advanced skills in a non-English language may need training to apply language skills to medical contexts and assessment to confirm readiness for clinical practice, whereas intermediate speakers may first need more instruction to solidify language abilities. Beginner speakers should learn cultural and rapport-building skills but may not be eligible for a formal medical language assessment for independent practice unless they first engage in more intensive, longitudinal education.

In medical Spanish specifically, a group of interdisciplinary experts have proposed standardized guidelines and learner competencies for educational interventions for physicians in training. Such guidelines should be modified to apply to the clinical responsibilities of other health care team members. By aligning language learning objectives with job responsibilities, it is easier to connect course outcomes with practical benefits for patient care. A clear understanding of how medical Spanish education ties directly to job duties and institutional accreditation requirements may help health professions schools justify adding such curricular elements in an already tight schedule.

Formalize A Process Of Progressive Re-Assessment And Documentation Of Clinician Language Skills

For clinicians who take an assessment exam to confirm language skills, language should not be viewed as a “one and done” approach, meaning whether they pass or fail an exam attempt. As with other skills, clinicians should be taught to regularly self-assess non-English language skills, since these may be gained or lost over time due to practice, coursework, or other experiences (or lack thereof).

Instead of each institution individually developing their own system of language skills tracking, these skills should be documented in a standardized way using validated tools. For example, the Interagency Language Roundtable scale modified for physicians has been validated and used successfully as a tool to improve the characterization of physician language skills. Other tools such as the American Council for the Teaching of Foreign Languages Can-Do Statements could be modified and studied for this purpose. Validated self-assessment tools for bilingual providers could be included in the steps toward physicians’ licensing and maintenance of certification requirements managed by medical specialty boards. Similarly, other health professions could incorporate self-assessment questions about language in their certification maintenance processes to document skills.

Provide Training For All Clinicians On Working With Medical Interpreters

Last but not least, medical education should teach clinicians best practices in working with certified medical interpreters as critical members of the health care team. All clinicians in training should be required to demonstrate the ability to communicate effectively with patients while working with medical interpreters, not as part of the “hidden curriculum” but rather as an intentional element of clinical skills training and practice. Even clinicians who are trained and confirmed as qualified bilingual providers should be able to perform these skills, as they likely will encounter patients who prefer care in other languages. While access to interpreters (for example, onsite, video remote, or telephonic interpreters) varies by medical center, the concepts of working with interpreters remain the same. Thus, training materials regarding working with interpreters, such as those created by the Agency for Healthcare Research and Quality, could be standardized nationally and evaluated for effectiveness to ensure high-quality instruction and achieved competencies.

A Call To Support Clinicians In Caring Effectively For Patients With LEP

We call for federal institutions that define national health policy, as well as health systems and educational institutions that oversee and accredit health professions training programs, to institute clear policies regarding qualified bilingual providers and align medical education strategies to achieve health policy goals. In so doing, medical centers, educational institutions, and individual clinicians will be better able to:

• Increase the number of graduating health professionals who meet the necessary qualifications as bilingual providers;
• Improve resource allocation by identifying language gaps in their service area, recruiting bilingual providers that match population languages, and planning for the necessary language assistance services; and
• Evaluate long-term effects on clinical outcomes, health care use, patient and clinician satisfaction, and national health policy objectives.

LEP populations have historically fallen through the cracks of US health care. Health policy adjustments that support clinicians caring effectively for patients who prefer non-English languages is our opportunity to improve health and health care for our increasingly linguistically diverse community.

Authors’ Note

Pilar Ortega receives author royalties from Saunders, Elsevier.