How Can We Get More Bilingual Health Care Providers?

Los Angeles County, where I live, is incredibly diverse, both racially and linguistically. According to the Asian Pacific American Legal Center’s 2008 report on Language Diversity and English Proficiency in LA County (pdf file), more than half of Los Angeles County residents speak a language other than English at home. “The 10 most frequently spoken languages countywide are: English, Spanish, Chinese, Tagalog, Korean, Armenian, Vietnamese, Farsi, Japanese and Russian.” The report lists 39 distinct languages and almost 10,000 residents speak another language not on the list. About 29% of county residents are Limited English Proficient (LEP), which means they have some degree of difficulty communicating in English.

All of these people will have some contact with the health care system at some point in their lives and ideally, at more than one point. And, according to the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality, having a health care provider who speaks the same language as the patient has lots of important benefits to patient care (internal cites omitted):

A growing body of literature finds that language concordance between patients and providers (i.e., both speak the patient’s primary language well) results in greater patient understanding, leading to increased satisfaction, better medication adherence, greater understanding of diagnoses and treatment, greater well-being and better functioning for persons with chronic disease, and more health education.

The report goes on to note that only some of these problems can be mitigated by having the conversation interpreted. Using an interpreter can also disrupt the human connection between provider and patient and curtail full discussion. Interpretation, no matter how competent, is somewhat cumbersome and inefficient.  This all means that having the health care provider be bilingual is by far the best solution, both for patients and providers. And often, cultural conceptions of health issues like pain, disability, and mental illness can be very important in understanding how a patient is describing symptoms or experiences, so a native speaker is the best.

The problem, of course, is that not all health care providers are bilingual. This means those who can speak another language are relatively valuable, so they can be more exclusive or take more high-paying jobs. If you are a patient who can afford to pay high rates or has great insurance, you may be able to get a provider who speaks your language, but you’re not guaranteed. And if you are a poorer patient and rely on emergency rooms and county health clinics for care, you just have to hope to get lucky. As I once heard it put, “If you’re a Cambodian therapist, you can basically write your own ticket. You’re not going to work at the County Department of Mental Health.”

So how can we go about getting more bilingual health providers, especially for relatively low-paying jobs to care for low-income patients? There’s no obvious answer. Here are some ideas, and their potential drawbacks:

  • Require all health care providers to become fluent in another language. Providers all go through some training and licensing procedures, so we could build in a language requirement. There are some obvious difficulties – how would we ensure languages were proportionally represented? would we match providers to areas where there was a need for the language they spoke? how do we make sure someone learns, say, Hmong? would the cost of administering all those language proficiency tests be better spent elsewhere in the health care system? It also doesn’t serve our goal of having providers be native speakers.
  • Recruit more native speakers of non-English languages to become health care providers. This could take a lot of different forms – scholarships and incentives for these people to enter training programs or medical schools, reaching out to younger kids to stimulate interest in health care professions, providing tutoring or other support resources, or a number of other methods. Most of these things would take a very long time before they resulted in a change in the makeup of health care providers. It’s also unclear how effective any of these methods are, and how much they cost.
  • One possible solution is always to throw money at it. We could dedicate a lot of funding to paying big salaries for providers who speak other languages. While that would probably work, and relatively quickly, it would cost a lot of money. And would continue to cost a lot of money to maintain. And, most importantly, would not do anything to increase the total number of health care providers who teach non-English languages and if more were induced to enter the profession because of the high salaries, it would cost more and more money over time. To compensate, there would be fewer and fewer health care providers overall, or some other significant effect on the health care system from the significantly shrinking resources.

Personally, I support a little bit of all three. (Equivocation is a policy-maker’s prerogative.) Increasing incentives for health care professionals to know and learn non-English languages, aggressive recruiting for native non-English speakers to become health care professionals, and paying bonuses or other incentives to bilingual providers. To make the best of the current situation, I also support training interpreters and ensuring they’re used appropriately.

Are there other policies you think would help the problem?

14 thoughts on “How Can We Get More Bilingual Health Care Providers?

  1. I am a physician, and I know a little Spanish from college. I work in an area where very few people speak Spanish. In fact, I’d be better off if I spoke Bosnian, which is something I never would have suspected when I started college in the 90s, not that there was a program in it at my institution anyway.

    You’re not going to get medical schools to add a language requirement at the schools themselves. I wouldn’t want them to. The medicine itself could fill eight years of studies, nevermind the four into which it gets compressed. I speculate that most medical students would resent and neglect foreign language studies when they’re trying to learn gross anatomy, neuroanatomy, histology, embryology, and microbiology all at the same time. High school and undergraduate programs are better places for foreign language studies. And, medical schools do note that students have completed FL studies in the application process, to the benefit of students who have done so.

    Interpreters aren’t ideal, but they’re more mobile than physicians, and I use them in my practice. In my case, the FL needed most often is one none of the three physicians in my practice knows, Bosnian. So, the patient must arrange for an interpreter when s/he visits the center, which is a reasonable means of bridging the communication gap without putting the onus on us to make the accommodation.

  2. Patrick – thanks for your input. I know that I personally am unlikely to be able to get medical schools to do anything. 🙂 I do recognize that getting the medical education establishment to change requirements or practices is notoriously difficult, another problem with relying on language requirements to serve the purpose.

    However, given the significant drawbacks to relying on interpreters mentioned in the post, for the purposes of this post in specific and for health care practice in general, I’m not comfortable throwing up my hands and saying we should just get used to relying on interpreters. I’ve proposed a couple of alternate policies that could increase native non-English speakers in the medical profession (and please note I never limited it to doctors, I also want to discuss nurses, pharmacists, etc) and I’d like this discussion to focus on that rather than on whether interpreters are adequate substitutes. We’ll also have to aree to disagree that requiring the patient to arrange for an interpreter is a reasonable requirement for them.

  3. I think Patrick does make a good point about the difficulty in choosing in school what language you’ll need later (assuming your school even offers more than the standard handful of languages). What might help is more research into effective ways to learn languages outside of school, so experienced medical personnel could more easily to their environments.

  4. interesting idea, Michaela. How could we provide incentives for medical providers to take the time to use those resources, though? All the providers I know work 12 hour shifts and guard their outside-work time for sleep and their families. Could we require language learning as part of a continuing education requirement? Rely on financial incentives like pay bonuses to reward those who do? Other ideas? I’m not at all convinced that simply having resources available is sufficient. (As I live in LA, with Berlitz schools and lots of other language resources, but still massive shortages!)

  5. This would obviously take a disappointingly long time to take effect, but I believe that one of the best long term solutions would be to increasing elementary language education. IIRC it is much easier to learn languages while young, it generally wouldn’t directly interfere with the busy lives of current practitioners or med students and would have lots of positive externalities. The main downsides are finding qualified teachers and the time delay. Even if every elementary and middle school in the country started school wide well run foreign language courses at the start of the next term it would be a over a decade before significant an significant change occurred to the percentage of bi+ lingual medical practitioners.

  6. My medical school offered Medical Spanish, which I was not able to take for several reasons, chiefly one of accessibility. (How’s that for intersectionality?) However, the main language spoken by my non-English proficient patients in that part of the city was Mandarin. We did not offer Medical Mandarin, although we could get live interpreters for outpatient appointments for Mandarin and Cantonese. Across the same city, the main languages were Cambodian and Vietnamese, and we could get live interpreters for those languages. All other interpreting was done via a telephone service, which has its own advantages and disadvantages.

    One problem with requiring medical students to study a particular second language (or third, if you consider learning the language of medicine) is that the problem of matching future caregivers language to areas of future language need would add layers of complexity to an already flawed system of where health care providers go. We could end up with areas which have a glut of Russian speaking orthopedists, but still not have any Tagalog speaking nurse-midwives.

    I think better training for all HCPs about how to use intepreters is a must. Many speak to the interpreter, rather than the patient. Many use family members to interpret, and in some cases, get consent for procedures from family members without any of the discussion being relayed to the adult patient. Many avoid using interpreters for reasons of time or cost, or percieved time or cost. And many hospital lists of interpreters are outdated or difficult to find after hours. In addition to basic education about using interpreters in health care settings, all medical students need instruction on the principles of culturally competent care. This can be provided in much less time than it would take to create truly fluent physicians in a given language, and creates caregivers who are more able to constructively interact with patients from a variety of cultures and backgrounds. These are stop-gap measures, but might improve things while waiting for your options 2 and 3 to take effect over time.

    Lastly, I would like to add that all the points you and others have raised also apply to Deaf patients and needing more HCPs who sign and who, whether hearing or Deaf, are able to provide culturally competent care to the Deaf community. I’m hoping to reach proficiency in ASL over the next few years as I finish my specialty training, so that I can communicate with Deaf patients, or the Deaf parents of my young hearing patients, without the need for an interpreter. There was no way for me to continue ASL classes given the structure of my medical school or residency programs, but should be during a fellowship. I guess that’s my own version of option 1.

  7. In Australia, there’s a shortage of rural pharmacists – people who grow up in a city tend not to want to live in rural areas; people who grow up in rural areas have a much higher chance of choosing to live in one as an adult. Pharmacy is addressing this by opening two regional pharmacy schools and providing scholarships and targeting recruitment to students from rural areas (particularly Aboriginal students) – rural and/or Aboriginal students tend to have lower marks/grades that urban students, so the recruitment part is critical. The first students recruited graduate this year, but there already seems to be an increase in young pharmacists in the rural workforce (they have placements in their final year). The tiny rural pharmacy where I work had FOUR trainees this year. Before that, one in ten years.

    Could the same thing work for languages? Targeting linguistic communities with lots of teenagers would seem to be a good way to ensure the language will be useful in coming years, and first generation immigrants have some similar barriers to study that rural students do – less access, poorer resources, a family that may not consider university a useful or usual career path.

  8. I like option two. On one hand, native speakers will have a level of fluency and cultural understanding that is hard to reach for non-natives. On the other hands, immigrant communities tend to be poorer, so increasing their access to (medical) education would also be a way of fighting poverty.
    I’m thinking of another option. There are some internships in med school, aren’t they? (I’m not familiar with American medical studies.) Programs that enable and encourage students to spend these internships abroad would also help language proficiency and intercultural competence. Of course, these would work better if the students already had some previous knowledge of the language. Since med-school is already quite busy, teaching languages better in K-12 education and, failing that, in pre-med, would be a good idea. I find it good that med-schools already consider language proficiency in their application process, this should be publicized a lot, if it isn’t already.

  9. Hmm…interesting.

    Linguist/translator jobs are difficult to come by (I would know!), especially if you haven’t studied the right type of language skills. While I emphasize the importance of medical staff including interpreters, like the post says, we are not the most convenient tools. Some things are just forever lost in translation, and medical emergencies or when a person is in pain is not the best time to discover that you have never learned the vocabulary for X, Y, or Z. Native speakers of other languages are also ideal, but that has translation-issue potential as well. I can go both ways, IME.

    I think offering incentives at medical schools for students with fluency, whether Mother-tongue or otherwise, in a given language, would be an idea. I suppose schools have a way of tracking where their graduates go on to work, and might be able to gauge, to an extent a need for certain languages. Work-study programs, loan-deferment programs, grants, bonuses, even loan re-payment programs (I am way out of my AoE on financial matters, but I think you get where I am going) for students with fluency in needed languages. Some of these work well for the military, so I imagine it might have “real-world” translation, pun-intended, capabilities.

    The best option, ideally, would be having medical staff who speak multiple languages, but U.S.-ians are so damned resistant to learning languages (outside of Romance languages), and to make it work, I think you would be looking at people who need to know multiple dialects of more than one language to make that model work. I don’t know. Maybe the language nerd is coming out. But based on the statistics provided in the beginning of this post, that is what we would be looking at needing.

  10. Please remember that for a segment of the population, disability interferes with the ability to acquire another language. I’m dyslexic- learning another language to fluency was pretty much impossible, at least with the resources used in school. I really hate the meme of ‘people who don’t want to learn another language are lazy and not trying!’ That isn’t quite happening on this post,but some of the replies are going down that path. Please remember than language acquisition is something that can be complicated by a person’s disability.

  11. Something to consider re: native speakers as their own interpreters. I’m not a native speaker of English, but most of my education has been in English. Although I can communicate conversationally quite easily in my native language, and understand cultural nuances, jokes, idioms, etc, I cannot effectively discuss any topic that’s covered in school at high school or later, simply because I never learned the relevant vocabulary, and never learned how to speak about that topic in any language that’s not English. I imagine this is even worse after medical school, since a lot of doctors I know can’t even speak in English without resorting to medicalese! This focus on native speakers would require that they learn, side-by-side, in both English and their native language. I’m not sure that’s reasonable given the existing workload.

    I think interpreters are in fact a *better* option than native-speaking medical professionals (or FL-trained medical professionals). For one, interpreters are professionally trained and experienced in their work, not tangentially-trained (the vast majority of a medical professional’s experience will be in English for the vast majority of medical professionals). And second, interpreters can provide an ally to the patient that’s constant regardless of the shifts in medical personnel that can accompany a hospital stay, for instance. It’s nice to have an interpreter who can speak to any doctor on staff, instead of waiting for the one doctor who speaks your language (at a sixth-grade level, if that doctor is me). This does, of course, presume that an interpreter is always available; but I think our money would be better spent on insuring the presence of interpreters than on insuring that doctors take X semesters of foreign language study or requiring medical professionals who are native-speakers of non-English languages to move to areas where their native language is useful.

  12. Just a reminder that this thread is not to discuss interpreters vs medical providers with language competence, it’s to discuss policies for broadening the proportion of medical providers with language competence. Since there’s such an interest in interpretation issues, I’ll do next Tuesday’s policy post on that issue, but I’d appreciate it if we could keep this thread focused on the issue at hand.

  13. I’m thinking that the best (although hardest, probably) way for this to be achieved is via a cultural shift in thinking about foreign language education – better foreign language education, provision of good and cheap foreign language classes, classes aimed at being able to communicate with native speakers of that language first and foremost, valuing multilingualism. For one, as other people have pointed out it’s much easier for young children to learn languages than mid-teenagers and adults, and then there’s also the fact that someone going to med school is probably not going to have a lot of free time on their hands. Although I’d also encourage good access to language classes for people in all areas of life.

    This is sort of topical for me right now because I’m doing a maths PhD and our department has some funding for “transferable” (i.e. non-maths) skills for PhD students that they figured out last year could be used for foreign language classes. As a result, we have the opportunity to do a language class free this year and a lot of people have taken them up on that – this although maths PhDs also don’t leave you with that much leisure time (although to be fair it was mainly second-years with I think some third-years, so nobody in their final year). Which makes me think that even if you don’t make a language requirement but simply build the option of taking language classes, for free, into the course, some people will take you up on it – I don’t think any of us would have done this if we’d have had to figure out how and organise everything ourselves as well as pay for ourselves, but clearly there’s interest there – and that structural issues in terms of access to language classes are still a problem. If you’re not in school or undergraduate language classes often end up costing money, requiring travel or there might not even be any in your area, etc. I’ve actually wanted to learn BSL or ASL for a while now but the money-and-travel issue has stopped me – a year’s education costs about twice as much as the language course I’m doing right now and wasn’t available at the uni language centre.

    Something that also needs to happen I think is that we shift the way we talk about languages. Bar Spanish, a lot of the languages that would be most practical for people to learn – in fact, most of the Asian ones – are ones that people usually frame as impossibly difficult and/or so different it’s hopeless (I’m learning Mandarin right now and it is really noticeable that there are much fewer people in my class than the Spanish and French classes, and almost everyone there has a reason for doing Mandarin specifically. Also, anytime I mention it people stare at me as if I’ve grown wings). This isn’t true but means that when people start learning languages they usually stick to ones like French, Spanish, German, which (bar Spanish) are not that likely to be useful in the situation you’ve described. In fact, fluency in another language is I’ve found very often held up to be some sort of amazing impossible thing in the English-speaking world.

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