Duke Medical Ethics Journal
Medical Multilingualism: A Call for Foreign Language Fluency Requirements for Post-COVID Medical School Admissions
By: Elaijah Lapay
Among the multitude of “emergency” and “pandemic response” teams and programs that surfaced in the height of the COVID-19 pandemic, one of particular importance for a specific subset of the United States’ population is the emergency bilingual groups of bilingual physicians and clinical staff that surfaced within hospital systems nationwide. As COVID precautions severely limited the number of in-person personnel allowed in hospital buildings, the ability to keep “linguistic congruence” and maintain language equity for every patient entering the hospital’s emergency rooms without the use of telephone interpreters became more and more difficult, prompting these “emergency groups” that had never emerged before in hospitals from Massachusetts to California (Abuelo, 2020). The proposed long term solution to the circumstances of these emergency bilingual groups has been a stronger call for a greater response on the other end of the pipeline from the physician end: a foreign language fluency requirement for American medical school admissions. The disproportionate impact of COVID-19 on Limited English Proficient (LEP) patients in the United States demonstrates the necessity of instituting a requirement of intensive language study in American medical school admissions. These efforts would work to encourage increased multilingualism and diversity among future physicians and dismantle inherent power-imbalances present between LEP patients and healthcare systems.
The lack of internal hospital infrastructure for LEP became a pronounced concern as details concerning COVID-19 outcomes for this population became highlighted. At the Brigham and Women’s Hospital in Boston, for example, it was identified early on in the pandemic based on hospital records that non-white persons have had disproportionately higher hospital admissions, yet when those at Brigham were compared to white patients who had similar chronic illnesses, little difference was found in the risk of death from COVID. A difference did emerge, however, for Hispanic and Latino/x patients who did not speak English; at Brigham, patients who didn’t speak much, or any, English had a 35% greater chance of death (Bebinger, 2021). A relationship between COVID admissions and LEP status is corroborated by another hospital in Boston that found hospital admissions rose from 15% LEP admits on March 25th, 2020, to 40% LEP on April 13, 2020; both of these statistics are compared to an average LEP admit rate of 6% for all of 2019 (Knuesel, et. al, 2021, p. 110). Considering the controlling of other factors related to social determinants of health like race and ethnicity, language access as a risk factor has been demonstrated to be more pronounced than simply race or ethnicity given the structural barriers to education and streams of information without knowledge of English, especially in the context of a global pandemic with change occurring rapidly and the demand for quick communication both inside and outside the clinical setting.
"Interpersonal patient outcomes are worsened when reliance on agents beyond the physician themselves is necessary, both in terms of efficiency and equity."
Nevertheless, it is important to note that these concerns of Limited English Proficiency as a serious risk factor for infection, disease, and inequitable care did not begin with the pandemic. For example, researchers studying factors related to blood sugar control in diabetic patients in California in the mid-2000s found that the percentage of patients with poor blood sugar control was similar among Latino patients with LEP and Latino English-speakers (Fernandez, et. al, 2011, p. 173). Alternatively, a difference in blood sugar control outcomes arose for those who had “language-concordant” physicians — physicians able to communicate in the language of the patient — versus those with language “discordant” physicians, with the latter reporting almost twice worse odds to control blood sugar control (Fernandez, et. al, 2011, p. 173). A similar finding on the role of language concordance is reflected in a study that found that blood sugar control increased by 10% and other diabetes-related control measures increased by similar amounts when LEP patients switched from a non-language concordant physician to a language concordant physician (Parker, et. al, 2017, p. 382-5). These findings, both prior to and during the pandemic, serve as evidence of the effectiveness of language concordance in measured patient outcomes.
Moving beyond solely clinical patient outcomes, there is importance in recognizing the impact of language concordance on the part of the patient-physician interaction from an equity and competency perspective. For example, the results of a survey designed to capture Hispanic LEP patient and physician resident perspectives on interpretation services found that those with a language concordant physician reported greater levels of comfort in discussing sensitive and personal topics regarding a patient’s health compared to use of an intermediary like a hospital interpreter (Kuo and Fagan, 1999, p. 549). The logic here is that direct linguistic competency provides cultural competency, a concern that is especially important to address in the context of medicine, where communication of symptoms and treatments can easily become — literally — “lost in translation.” Consider the following exchange between an Interpreter (I) and LEP Patient (P) where italics signify exchanges occurring in Spanish (Elderkin-Thompson, Silver, and Waitzkin, 2001, p 1353).
215 I: She said-
216 P: [The liquid is coming out like this. (Points to her fingertips)
217 I: Sometimes coming out...of her hand
218 P: (1) First it comes cold and then something hot
219 (2) because...all of the blood wants to break out,
220 it wants to come out.
221 I: She said- she feels that somethin’ wants to come out of her finger.
Photo credit to Storyblocks
The above patient is of a rural Latino immigrant whose response regarding coldness in his fingers is a reference to a cultural belief of the necessity to maintain a hot-cold balance in order to maintain wellness, and that the role of healthcare is to provide interventions for this correction of internal temperature imbalance (Elderkin-Thompson, Silver, and Waitzkin, 2001, p 1353). This nuance in concern was lost on the part of the Spanish speaking interpreter, who failed to communicate concern of temperature, and instead communicated a very different interpretation of feeling in the fingers. Critical differences in health understanding were lost, which would not have occurred given a language concordant physician, who would have been able to understand the impact of views of temperature, as opposed to having to interpret the idea that “somethin’ wants to come out of her finger.”
When examining these value of the patient-physician interaction — and in particular the potential danger when this relationship is not fostered in direct conversation — three communication processes in the physician-patient interaction associated with improved health outcomes have been identified: the amount of information exchanged between the patient and physician, the patient's control of the dialogue, and the rapport between the patient and physician (Kaplan, et. al., 1989, pg.s 123-5). All three of these factors have the potential to be considerably hindered when there is a lack of patient-physician language concordance stemming from hesitancy in communication, lack of cultural or circumstantial understanding of the patient, and lack of interpersonal relationship building, even if using an “ad hoc” family member or professional interpreter. Furthermore, due to the intermediary of interpreters in these settings, it can be difficult to center the patient in dialogue and foster interpersonal rapport when an intermediary is the one facilitating communication. An additional consideration is the time to use interpretation in constrained time settings — often imposed on by physicians, especially in times of medical emergency like COVID-19 — already limits the potential amount of information exchange. One final, and crucial, consideration, is the chance of interpretation error, which exists regardless of the skill of interpretation. One study found that up to 52% of recorded patient-physician interactions mediated by an interpreter had serious miscommunication problems that affected either the physicians’ understanding of the symptoms or the “credibility” of the patients’ concerns (Elderkin-Thompson, Silver, and Waitzkin, 2001, p 1345). Interpersonal patient outcomes are worsened when reliance on agents beyond the physician themselves is necessary, both in terms of efficiency and equity.
It is in light of attention to the physician that emphasis has been repeatedly made to the necessity of bilingual and multilingual physicians able to challenge lapses in the physician-patient interaction and improve patient outcomes and equity in the healthcare system. Physicians prior to the pandemic repeatedly prioritized and emphasized the need for “training or hiring bilingual health professionals to meet the care needs of [the LEP population]” (Hornberger, et. al., 1996). A similar article simply found it impractical to suggest as a solution the encouragement of bilingual physicians due to limitations of resources, and found it more feasible in the short run to — worryingly — investigate family interpretation (Kuo and Fagan, 1999, p. 549-50). These challenges were resurfaced in COVID, when medical interpretation access became significantly more logistically challenging due to social distancing and hospital precautions. One hospital in the context of COVID-19 found notable success in the creation of a “Spanish Language Care Group” made up of physicians of a particular degree of bilingualism, which emphasized “the power of cultural and linguistic competency, and the resiliency that diversity brings to a hospital’s professional staff” (Knuesel, et. al, 2021, p. 111). This article in particular concludes by stating that the formation of this Spanish Language Care Group forwards an “ongoing conversation about how [hospitals think] about diversity, equity, and healthcare access in these pandemic times and into the hoped-for beyond” (Knuesel, et. al, 2021, p. 111).
Thinking critically about these questions in respect of both the needs and outcomes of LEP patients, as well the impact of bilingualism and equity in the hospital setting, it is important to investigate how to move toward the “hoped-for beyond” and the long term solutions to lapses in care that some in the 1990s could not even begin to consider. Pilar Ortega, MD, takes a critical look at the current system of medical education as one crucial factor to address these concerns. Ortega has found that only 7% of all medical schools document medical Spanish curricular content, and even then, it is considered an elective (Ortega, 2018, p. 1277). Ortega further notes that “although nationally accepted undergraduate and graduate medical core competencies already recognize the importance of communication skills for graduates, specific attention to the skills needed to communicate with LEP patients is needed” and that “national academic organizations should recognize medical Spanish as an important corollary, if not required, component of U.S. medical education” (2018, p. 1277). In other words, a greater emphasis on Spanish and forign language competency in general must be made for incoming and current medical students, given the increasing cost this lapse has on LEP patients in outcomes and healthcare equity.
Another physician, Carolina Abuelo, has made a similar but more nuanced argument in the context of the pandemic that calls for action even before medical institutions themselves: “The same reason COVID-19 is disproportionately impacting Black and brown communities is the same reason medical professionals are predominantly white: social and economic inequality” (Abuelo, 2020). Institution of bilingual fluency requirements for medical school admissions, co-opted with greater efforts to have medical training for languages beyond English, would provide a positive push toward diversification of both thought and bodies in the medical system, valuing the voices and abilities of those that can, in turn, close the patient-physician concordance gap in the clinical setting further on down the line. Those critical of physicians like Ortega and Abuelo must acknowledge how current medical school admissions are not directly reflective of either existing federal standards for culturally and linguistically appropriate services (CLAS) in healthcare systems nor the general disparity of LEP speakers to their counterpart physicians. For example, one study highlighted how while 37% of resident physicians spoke at least one non-English language, in most cases the languages they spoke were not those in greatest need by the US LEP population of over 25 million (Ortega, 2018, p. 1276; Diamond, et. al., 2020, p. 2289-90). To recognize the concerns from the resident physicians of healthcare systems is to recognize that those in the next generation of healthcare systems need to better reflect the America that they serve, especially linguistically.
It is important to recognize, in closing, that additional requirements of languages in need like Spanish in medical school admissions and encouragement of linguistic diversity in medical school student bodies and education is not the end-all be-all for the larger gap in health outcomes for LEP patients. Nor should the takeaway be that there should not be an investment in medical and qualified interpreters in hospital systems that seek to fill interpretation and linguistic gaps in the short term, especially for less commonly spoken languages and in spaces where physicians are not the pathway for treatment. However, in light of COVID-19 exposing the critical role that bilingual and multilingual practitioners have in patient outcomes, equity, and diversity in the broader medical and clinical system, it is up to medical schools to move toward developing long term — as opposed to current largely short term — systemic solutions in the medical profession for LEP patients and demonstrating the feasibility of increased physician-patient language concordance through a reassessment and adoption of bilingual and multilingual aspects in medical school core competencies, starting first and foremost with admissions. These and other arguments emphasize the important role that medical schools have in setting the expectations for the hospital and clinical system — the “next generation” of the clinical workforce — and that medical schools, by placing a valuation on bilingual and multilingual applicants, are placing a similar valuation on a physician population that reflects a rapidly culturally and linguistically diversifying America.
1 It is perhaps more accurate to state “lost in interpretation,” as translation refers to the transcription, or writing, of one language from another, while “interpretation” refers to the act of speaking or orally communicating one language from another.
Review Editor: Danika Dai
Design Editor: Harris Upchurch
1. Abuelo, C. (2020, August 25). Why we need more Spanish-speaking doctors. US News; World Report. https://www.usnews.com/news/healthiest-communities/articles/2020-08-25/why-we-need-more-spanish-speaking-doctors
2. Bebinger, M. (2021, April 27). Pandemic imperiled non-english speakers more than others. Kaiser Health News. https://khn.org/news/article/pandemic-imperiled-non-english-speakers-more-than-others/
3. Diamond, L. C., Mujawar, I., Vickstrom, E., Garzon, M. G., & Gany, F. (2020). Supply and Demand: Association between Non-English language–speaking first year resident physicians and areas of need in the USA. Journal of General Internal Medicine, 35(8), 2289–2295. https://doi.org/10.1007/s11606-020-05935-7
4. Elderkin-Thompson, V., Cohen Silver, R., & Waitzkin, H. (2001). When nurses double as interpreters: A study of Spanish-speaking patients in a US primary care setting. Social Science & Medicine, 52(9), 1343–1358. https://doi.org/10.1016/s0277-9536(00)00234-3
5. Fernandez, A., Schillinger, D., Warton, E. M., Adler, N., Moffet, H. H., Schenker, Y., Salgado, M. V., Ahmed, A., & Karter, A. J. (2010). Language barriers, physician-patient language concordance, and glycemic control among insured latinos with diabetes: The diabetes study of northern california (DISTANCE). Journal of General Internal Medicine, 26(2), 170–176. https://doi.org/10.1007/s11606-010-1507-6
6. Hornberger, J. C., Gibson, C. D., JR., Wood, W., Dequeldre, C., Corso, I., Palla, B., & Bloch, D. A. (1996). Eliminating language barriers for Non-English-speaking patients. Medical Care, 34(8), 845–856. https://doi.org/10.1097/00005650-199608000-00011
7. Kaplan, S. H., Greenfield, S., & Ware, J. E., Jr. (1989). Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Medical Care, 27 (Supplement), S110–S127. https://doi.org/10.1097/00005650-198903001-00010
8. Knuesel, S., Chuang, W., Olson, E., & Betancourt, J. (2020). Language barriers, equity, and COVID-19: The impact of a novel Spanish language care group. Journal of Hospital Medicine, 16(2), 109–111. https://doi.org/10.12788/jhm.3542
9. Kuo, D., & Fagan, M. J. (1999). Satisfaction with methods of Spanish interpretation in an ambulatory care clinic. Journal of General Internal Medicine, 14(9), 547–550. https://doi.org/10.1046/j.1525-1497.1999.07258.x
10. Ortega, P. (2018). Spanish language concordance in U.S. medical care. Academic Medicine, 93(9), 1276–1280. https://doi.org/10.1097/acm.0000000000002307
11. Parker, M. M., Fernández, A., Moffet, H. H., Grant, R. W., Torreblanca, A., & Karter, A. J. (2017). Association of Patient-Physician Language Concordance and Glycemic Control for Limited–English Proficiency Latinos with type 2 diabetes. JAMA Internal Medicine, 177(3), 380. https://doi.org/10.1001/jamainternmed.2016.8648