COVID Lesson Learned – Improving Language Access By Changing Medical Education  

The COVID 19 pandemic revealed much to be improved in the United States’ approach to health emergencies and the reality of language-based discrimination. All too often, the lack of real time, qualified interpreters and the paucity of accurately translated necessary health care information resulted in individual and community harm. The reality of health care disparities based on language has been laid bare over and over again since the pandemic’s start in March 2020. 

For example, a recent Journal of General Internal Medicine study, “Racial and Ethnic Disparities in Hospital Admissions from COVID-19: Determining the Impact of Neighborhood Deprivation and Primary Language,” strikingly concludes that: 

“…non-English-speaking patients within each minority racial/ethnic group had a higher odds of hospitalization than those who primarily spoke English. To our knowledge, this is one of the first times primary language, at the individual level within and across minority populations, was identified as a risk factor for hospitalization from COVID-19… 

Minority communities, specifically non-English speaking and those with lower literacy rates, are more likely to be unaware of public health recommendations and are more susceptible to misinformation, which compounds a deep-seated distrust in healthcare due to historical discrimination and personal injustices. To combat this, we must ensure all forms of communication are available in different languages and with a robust community dissemination strategy.” 

With COVID now receding as a life-changing concern for most Americans, our attention must shift to the lessons learned from the past two years of our ongoing health emergency. What must be done differently the next time we are afflicted by a pandemic? How can we better communicate with people who are limited English proficient or have communication disabilities? What is the plan for the next time? 

Federal law and the U.S. Department of Justice are clear about the legal foundation for effective communication in emergencies. 

The Department of Justice has historically been unequivocal about the federal requirements for language assistance and the necessity for planning for emergencies and disasters to prevent language and national origin-based discrimination. Such planning helps ensure people have equal access to emergency, life-saving services and information in languages they understand. It’s not just sensible advice, it’s the law. 

According to the Department of Justice: 

“… complying with [federal legal] requirements becomes even more important during emergencies and disasters in order to ensure that no one is unjustly denied the services and support they need during times of crisis, when their physical safety or well-being are often at greatest risk, and when many of the resources they might otherwise have drawn upon for support may not be available.  

Proper planning to comply with Title VI [of the Civil Rights Act of 1964] [language access and assistance] requirements avoids complications imposed by the exigencies of emergencies and disasters.” 

With the legal foundation and lessons learned from COVID in the communal knowledge bank, let’s look to the future and focus on HOW to change attitudes and understanding about the life-preserving importance of language access in times of crisis. Not repeating what the Journal of General Internal Medicine concluded: identifying the COVID emergency as “one of the first times primary language, at the individual level within and across minority populations, was identified as a risk factor for hospitalization from COVID-19” should be an unconditional societal priority 

It is commonly understood that health care providers have much to gain by having effective communications with non-English-speaking patients. However, despite the linguistic diversity of the United States, 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 Limited English Proficient (LEP) population when students graduate and become medical practitioners. 

Health Affairs, in a 2021 study, “Language Is Not A Barrier—It Is An Opportunity To Improve Health Equity Through Education,” identified medical and clinical education’s failure to teach future practitioners to communicate with LEP and disabled people, and the legal consequences of not doing so. These educational gaps play a significant role in health care often not providing effective, meaningful, and compliant language services.  

According to Health Affairs: 

“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… 

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.” 

Health Affairs has several recommendations for alleviating the language access gap in clinical education.  

1. “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.  

[Existing] 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. 

2. 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. 

3. 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). 

4. Provide Training For All Clinicians On Working With Medical Interpreters: [M]edical 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. … [T]raining 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.” 

Before the next pandemic or other health emergency occurs, governments, health care providers, universities, non-profits, stakeholders, linguists, and language services providers should collaborate on how to avoid the searing, language related, life-changing experiences so many endured since March 2020 for want of appropriate language services.  

Health Affairs recognizes the essential need for different approaches to serving non-English speaking communities, concluding:  

“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.”