Language Equity in Medical Education

On By amroundsIn AM Podcast, AM Podcast Transcript

On this episode of the Academic Medicine Podcast, Pilar Ortega, MD, MGM, Débora Silva, MD, MEd, and Bright Zhou, MD, MS, join host Toni Gallo to discuss strategies to address language-related health disparities and enhance language-appropriate training and assessment in medical education. They explore one specific language concordant education framework, Culturally Reflective Medicine, which recognizes and supports the lived experiences and expertise of multi-lingual learners and clinicians from minoritized communities.

This episode is now available through Apple Podcasts, Spotify, and anywhere else podcasts are available.

A transcript is below.

Read the article discussed in this episode: 

Check out the complete Academic Medicine and MedEdPORTAL language equity collections:

cartoon graphics of people's faces arranged in a circle

Transcript

Toni Gallo:

Welcome to the Academic Medicine Podcast. I’m Toni Gallo. To provide inclusive and equitable care to all patients and communities, we must address language-related health disparities. On today’s episode, I’m joined by Dr. Pilar Ortega and Dr. Debora Silva to discuss language equity in medical education. Dr. Ortega and Dr. Silva have curated a collection of Academic Medicine articles on this topic. You can find that collection on academicmedicine.org. The goals of the collection are really to increase awareness of the evidence-based resources that exist for advancing language equity and to support you all in engaging in scholarly work related to language and health.

During our conversation today, we’ll talk about what language equity is and where the scholarship in the field stands. And then one of the authors of one of the papers included in the language equity collection, Dr. Bright Zhou, will join us to discuss their culturally reflective medicine framework and the intersections between that framework, language education, and language appropriate care. So let’s start with introductions. Pilar, Debbie, could you get us started?

Pilar Ortega:

Absolutely, muchas gracias. Thank you so much for inviting me to this podcast. My name is Dr. Pilar Ortega. I am Vice President for Diversity, Equity, and Inclusion at the Accreditation Council for Graduate Medical Education or ACGME. Soy bilingüe en español y en ingles. I am an emergency physician. I’m a medical educator, and I have an appointment as well at University of Illinois College of Medicine, and I do a lot of active research as well on physician language proficiency. So it’s really exciting to be here to talk about this important topic with you.

Debora Silva:

Saludos y gracias por la invitacion. Mi nombre es Debora Silva. And I am right now the interim dean of the University of Puerto Rico School of Medicine. I’m also a professor of pediatrics and a pediatric hospitalist and a medical educator. My area is accreditation, and I’ve been working with Pilar now for maybe 3 years, 4 years in what’s language appropriate health care. So I’m very excited to be here and talk about a topic that is very important to me.

Toni Gallo:

Thank you both for being on the podcast today. Pilar, maybe you can start with a little bit about what language equity is and what’s its role in addressing health disparities and really improving patient care.

Pilar Ortega:

Yeah, great question. I really think it’s important for us to frame this conversation around language equity within a broader understanding of what health equity is. So health equity is when every person has a fair opportunity to achieve their best health. And within this framework, when we think about language equity, that’s when every person, regardless of their language skills and regardless of their language preferences, is able to have a fair opportunity to achieve their best health.

And the reason that this language equity concept is so important in health care is that we know from data, that when a person receives their health care and health communication in their preferred language, their outcomes are better. So they are healthier, they are able to understand about their health. And it’s also, of course, common sense, right? If we are able to understand the treatment instructions that we’re receiving, if we’re able to participate more in our own health, and have greater agency in our own health decisions, that we’re going to be able to live healthier lives. And so that’s really the core and why language equity is so critical in actually addressing health disparities for populations whose language preference is not the dominant language in which they live.

Toni Gallo:

Debbie, both you and Pilar mentioned in your introductions that this is very important work for both of you. And I wonder if you can tell us just a little bit about how did you get involved with language equity and scholarship in this area?

Debora Silva:

So I can start. Well, I’m from Puerto Rico, and we speak Spanish. So we learn English, so I am bilingual, but English is really my second language, rarely spoken. So for us, our patients are Spanish speakers, and our curriculum at the medical schools are in English and Spanish, right? So it never occurred to us, and to me specifically, that there would be a need for my patients to have language concordant care until Hurricane Maria came and 500,000 Puerto Ricans left the island. And that’s when I started thinking, oh my God, who’s going to take care of my patients in their language? They don’t speak English.

So that’s how I started thinking about it. And I got involved through MedEdPORTAL in researching how to take better care of our patients. And that’s when I met Pilar because I started researching who is doing this and who is a trailblazer, and taking this topic and taking it to a curriculum so we can teach our students to do it better.

Toni Gallo:

And I want to encourage listeners. If you haven’t checked out the MedEdPORTAL collection on language equity teaching and learning resources, please do that … mededportal.org … you’ll be able to find all of those. Pilar, how about you? How did you get involved in this work?

Pilar Ortega:

Yeah, and I never tire of hearing Debbie’s story and her passion for language and living really in an environment that is truly translingual. So there’s a constant flux between English and Spanish. It’s really, really beautiful where you teach, Debbie, so it’s really exciting to see it in that context. My context is kind of different actually. The communication piece has always been something that I’ve been passionate about and I started getting involved in really because also my own lived experience.

In my own lived experience, I really came from a community that … my own community, my own family was primarily Spanish speaking, and I was able to observe how different access to health care was for my family and my community compared to others who maybe didn’t have a language preference other than English. And I especially started seeing that more so when I left my childhood home and started entering the arena of higher education. As being part of a first generation going into college in my own family and seeing that there were others who had very different backgrounds and lived experiences from my own, I started noticing these gaps even more and more prominently.

And I started getting more education on it and learning how language and just the communication piece is actually the principal thing that doctors use to treat patients, right? So we spend all this time in medical school with a lot of other components that are not communication, so learning how to do, for example, a physical exam, or learning what lab test to order, or learning what imaging test to order. And there’s so much emphasis in clinical practice on those pieces. But actually, the thing we use the most when we’re taking care of patients is communication.

And so as I’m realizing that these gaps are even more significant for patients and families and communities who don’t have that direct communication with their clinician, I thought this is a huge problem. And I’ve always felt quite fortunate that I grew up in the type of household where a language was given to me, right? When you learn a language as a child, it’s easy. You just absorb it. And so I have the chance to grow up bilingual, and then realize this is a skill that maybe others can acquire too, and I can help them with that.

So that’s really kind of how I started developing more of an expertise in the language aspects so that I can leverage the gifts that I have from my own upbringing and kind of share that in a different way with my own colleagues and peers.

Toni Gallo:

I appreciate you both sharing your stories for us today, and I think this is a good way to get into some of the scholarship that’s out there. Both of you have been active researchers and writers on this topic, but maybe we can get into a little bit of what the literature is like right now, kind of what’s out there, what sorts of resources have been published that our listeners might want to learn about. Debbie, do you want to get us started?

Debora Silva:

Sure. So the need for language concordant care has been established through many, many, many years, more than 25 years in different journal articles. So that has been established, and it still is. You still see new journals and articles coming out that keeps establishing that need. What we’ve seen is less in the evidence-based techniques of how to teach language concordant care and the intersection with culture because you cannot separate it. So, for example, in our Academic Medicine collection, we have around 8 articles that have to do specifically with that need, and then we have 13 that are evidence-based articles on how to teach it, and around 9 articles that are related to that intersection. But those articles are incredibly important because you cannot separate our patients into different silos. Their language is an integral part of their culture, and the students need to learn how to take all of that into consideration. In MedEdPORTAL, for example, right now, we have around 10 to 20 published modules in our collection, and only 5 of them are about medical language education. So we do need more medical language education tied to culture.

Pilar Ortega:

I totally agree with Debbie, and I would also add some of the themes that have come up in the literature over time around the issue of language-appropriate care and medical language education have, to a large degree, been limited by the data that has been collected. For example, who collects data about language proficiency of physicians, right? Not very many organizations, not very many institutions ask about the language skills of physicians, and medical students and residents, and so it’s very hard to actually do research asking questions around, is it better if a doctor speaks the language of the patient? Are the outcomes better?

And to tie the work that we do in medical language education to eventual patient outcomes, it’s very hard to do, particularly if we don’t really track and collect data on language proficiency, which of course, is a dynamic factor, right? So it’s kind of complicated and something that we need to check in on over time. Language is one of those things if you don’t use it, you lose it. Also, you can gain it over time depending on different experiences and things. I think partially as a result of that, some of the existing literature focuses on other strategies to address language appropriate care, which is so critical, like medical interpreting. So I can’t overemphasize the importance of our colleagues and medical interpreters who really help not only as conduits of information, but oftentimes they’re advocates and help us provide better care to our patients.

As physicians, we live and work in a society where many languages are spoken. And so we of course may not speak all the languages that our communities and patients speak that we need to be able to provide excellent quality care to all of these patients, regardless of what languages we speak and they speak, but we haven’t really done a lot of work on the language concordant piece and really capitalizing on the language skills that many physicians do have or would like to gain.

And so I think there’s an opportunity to do both, and that’s something that I’d love to see increase. And I think would also help physicians and clinicians who come from marginalized backgrounds. So I think that’s another theme that we are seeing more so in the literature now, is focusing on that experience of the learner who comes from a marginalized or minoritized background. And language is one of those characteristics that I think there’s opportunity to further explore, which is how does a learner who comes from a minoritized linguistic background or have multilingual skills, how do they contribute? How do they want to contribute? What are the learning opportunities that can help them really flourish and thrive as a physician, researcher, educator, and so forth? So I think those are trends that hopefully we’re going to see more of in the literature as we progress in this field.

Toni Gallo:

I want to encourage our listeners, if anybody is doing work in this area, please send it to Academic Medicine and MedEdPORTAL. We recognize how important it is, and we want to hear about the innovative programs that you have or the work that you’re doing at your institution. So please send it in to us.

I’d like to invite Dr. Bright Zhou into our conversation. Dr. Zhou is the author of “Beyond Humility: Empowering Minoritized Learners Through Culturally Reflective Medicine,” and their paper is one of the ones included in Academic Medicine‘s language equity collection. Bright, could you introduce yourself for our listeners?

Bright Zhou:

Thank you so much. 大家好，我叫周明潇. My name is Bright Zhou. I am a current third-year family medicine resident at the Stanford O’Connor Family Medicine program. And as mentioned, I really drew upon a lot of my own personal lived experiences and my patients’ experiences to conceptualize this culturally reflective medicine framework, along with one of my mentors, Dr. Alan Louie. Previously was an archeologist and have some social science background there that we can dive into as well. Also, I should mention I’m currently teaching a course on clinical Mandarin here at Stanford, the only clinical Mandarin course at Stanford. And so I’m particularly interested, as well as everyone else here, on the medical education delivery of linguistic concordant medical education.

Toni Gallo:

And I think we’re going to get into a bunch of that in our conversation today, but maybe you can start with a little bit about the framework that you write about in your Academic Medicine paper. Tell us a little bit about what it looks like and how it might play out in practice.

Bright Zhou:

I think I would like to start with a story. I think we’re all storytellers in medicine. When I was in medical school, I had a session on cultural humility, and it was a single person teaching this class for a large group of diverse medical students. And I remember that that workshop tried to cover cultural aspects of every single patient that we might be able to see. And as you can imagine, in the limited amount of time we have in medical education, I think it just kind of glossed over everyone. And I remember thinking for the Asian section, getting ready and excited to hear about what my people might need or what my fellow students would learn, and it was just something along the lines of we prefer hot water over cold water, and then we moved on. And I remember thinking, that is true, but there’s so much more in the care and delivery of Asian patients, but also East Asian, South Asian, and all the distinctions within.

And so culturally reflective medicine came out of, I think, that core pivotal moment where I was thinking about how might we reconceptualize the delivery of these previous traditional cultural humility classes, and also diving into the background of where did we come from, from cultural competency to cultural humility. But even moving forward, where might we go beyond that? Pilar, you had mentioned that there’s limited data in terms of tracking the fluency of our clinicians, and I would also add that there is also limited data in the level of fluency and helping to keep us accountable in terms of that. And I think the difficulties that I was initially encountering was who, if anyone, could be an expert in everything? Right? And rather than creating a curriculum where we were trying to find one person who could be an expert on every single culture, we began to pivot to a framework where we were relying on the expertise of those who are already in the system. So in 2018, 44% percent of clinicians in the United States were non-Hispanic White clinicians, so the experts are already in the room.

And so rather than asking one individual to become an expert on every single culture to deliver a better cultural humility workshop, cultural reflective medicine asks the individual learner, the learner and their mentor, and then the learner, mentor, and the patient triad to reflect continually inside. And so in brief, what the framework asks is, how can these cultural concordant or language concordant experiences, so when I am caring for another Mandarin-speaking patient, how can I find other Mandarin-speaking doctors, both in terms of my classmates and in terms of my mentors? And how can we reflect on what went well, what went wrong? What were some of the unique elements of that experience that might have been because of my gender presentation, of other elements that isn’t just culture, isn’t just language, and begin to reflect and iterate on that process.

And so culturally reflective medicine is not a one-time workshop, but it’s an iterative process that anyone with a culture, which is everyone, can practice to better understand the care delivery for their own patients. I love that definition of health equity, to ensure that every patient gets the health care that they rightfully deserve here in our diverse nation. So that is CRM, culturally reflective medicine, in a nutshell, and I think there’s lots of examples that we can dive in. And I argue that we’re already doing it. And so the second element of CRM is to make sure that we have shared vocabulary for research, but also for compensation of this work that we’re doing. Can we say, “I’m not just interpreting for my patient, I’m actively practicing a cultural reflection in this moment”?

Pilar Ortega:

I think that’s super fascinating, Bright, and thank you for sharing. And I especially appreciate this idea that our patients and our learners are experts in their own experience. And the second part that I think really stood out to me about what you said is that we all have a culture and we all have something to contribute. And I think sometimes, I think in the U.S. kind of sociolinguistic arena, we sometimes have this false idea or false notion that those with a culture or those with a language, it’s othered by definition. It’s only those who are different from the norm or different from the dominant culture or dominant language are the ones that have that culture or linguistic attribute, but we really all have a rich background that I think we can bring to the table in a way that is truly what inclusion is about, where everyone can feel like they are an expert in their own lived experience, they have something to contribute. I think that’s a really positive way to approach it, from an education and a learner centered perspective.

Debora Silva:

If I can add to that. One of the things that comes out of the framework in the reflection part is the reflection on bias. So when I was reading through your paper, I kept thinking about the experiences of the students within the context of a culture, which it’s not their culture, right? And how that professional identity might be influenced by many things, including, and Pilar, you can correct me if I say it wrong, but racial linguistic hierarchy. The first time I read that, I thought this is so real. So this is our student. They have their culture, their primary, secondary language, and they’re in the culture of medicine within that triad. But their first responsibility, it’s to the patient but also to their learning. So they’re doing many things at the same time. And through reflection, and I really liked how you tie reflection and self-directed learning, specifically for students to identify the objectives of what they need to learn or what they learn from that interaction, I think it addresses a lot of the bias that we all have, and we need to work on it. The fact that we both come from what seems to be the same culture and that we speak what seems to be the same language, it doesn’t have much to do with having the same experiences. And when we’re talking about concordant care, we really are addressing our lived experiences, and the expectation of our patients cannot be based on our experiences. So that part, that reflective part is very important.

Bright Zhou:

I love that. Thank you so much, Debbie, for bringing that up. I think the CRM educator is a facilitator, but the content expert, as we are all saying, is the patient, is the learner, is that person who speaks that other language. And so rather than focusing on one person who can teach a class on everyone, we ask how can people who are already existing in medicine help one another reflect and create those learning objectives? And I think it really opens the space for what about cultures that are truly not represented, not only from the student level, but also the faculty level and different mentorship levels? I think it begets the question, how can we make sure that there are mentors who can provide that facilitation? But exactly that, CRM is a facilitation of self-directed experiential learning, and it acknowledges …

I think we’re moving, in medical education at large, into this understanding that our learners are adult learners, and that we are … If I can just say this idea came from me as a learner, I was a medical student who kind of came up with this framework, and I think really giving our adult learner students the freedom to be able to direct their own learning, particularly with regards to culture and language, that they are the expert in.

Toni Gallo:

This also sounds, I think another theme that’s kind of run through what you all are saying is almost breaking down hierarchies, especially in education here, thinking about the patient and the learner as the one with the expertise. Bright, you mentioned that the framework is really based on the lived experiences of the trainees. And maybe you can talk a little bit about what you hope the trainees will get out of this process, but then also what might their mentors get out of it, or their classmates, or anyone else who’s involved?

Bright Zhou:

Yeah, that’s an excellent question. I think a lot of the initial pushback or feedback I had about this was the so what? So you now have come to a deeper understanding of your own culture or maybe a more nuanced understanding. So what? And I think the second angle, the application of CRM is a couple stages. So I mentioned one is CRM allows there to be greater accountability. And so for instance, I feel like it is really only another Chinese-American who can give me feedback on my Chinese-American health care delivery, or it really has to be someone really from my culture who can say, “Maybe your language skills need a little bit more improvement,” or “Maybe your cultural understanding could have a little bit more breadth in this way.” And so the explicit partnership or acting of checking in with one another about what was your interpretation of that experience introduces accountability so that we are not left without these sorts of larger practice changes.

But then the other thing, what we were saying is the compensation, and I really hope that a mentor who comes out of this, really, the ideal would be that if this is a accepted form of medical education, a mentor can have time protected. It’s not just … So much of the mentorship that I’ve gotten from my mentors, I feel like, has been gratefully, but on their own personal time. In between patients or in between office hour sessions, we have a brief discussion about this one shared cultural concordant experience. And could we maybe carve out more explicit time where someone is actually practicing culturally reflective medicine and being compensated for the labor that many people who are occupying second and third cultures often are expected to do for free?

And then lastly, the real goal is to come up with actual practice changing insights. And so one of the vignettes I was talking about Mandarin, and I was saying I came into a lot of my sessions as a learner, early learner, believing that our bilingual patients or missing their bilingualism, and seeing our patients as just limited English proficiency, you don’t really speak English, I have to speak Mandarin to you. And that vignette, if I can just briefly summarize it, I think a lot of my professional identity formation from that Western perspective of I’m the doctor, you’re the patient, left me feeling like, okay, well then I have to tell you everything in Mandarin. And often when my patients would respond back in English and I had assessed it to be more broken or maybe less fluent, I was not giving them that bilingual credit that I myself found so much pride in.

And so actual practice changing thing that I’m doing now is asking my patients, “I’m bilingual. You’re bilingual. What language do you want to speak in? We can do either.” And I think that has just been so much better for building rapport, building trust, and also just minimizing my own nerves and my own experiences where I’m thinking, are you judging my Mandarin skill? Do you think I’m not speaking well enough? And just really acknowledging the strength of our bilingualism, our shared bilingualism. And I think that’s a very simple change in practice that really only another bilingual provider could have offered. So that’s where I’m saying like CRM really allows you, as multiple people have these shared experiences … I’m seeing some nods here from Debbie and Pilar. Maybe you also have had this shared experience. Once multiple people realize, okay, this is a shared experience, we can maybe collectively decide that’s something that we should all change, is ask our patients what language they prefer to speak in, even if we are all bilingual, and not just jumping into the Spanish or the Mandarin or the not English language because maybe they also prefer to speak in English in that moment.

Pilar Ortega:

Absolutely Bright. I could actually talk on and on just about this one issue because oftentimes our patients, not only do they maybe prefer Spanish or maybe prefer English, sometimes it’s a combination. Sometimes what they want is actually have the conversation in whatever feels right, un poquito por aqui en Español then a word in English, etc. Because that’s how multilingual people actually operate in terms of their mental processing. If you ask me whether I had a dream in English or in Spanish, I can’t tell you because for me, both languages are kind of equally salient in terms of my usage of them, right? So oftentimes a lot of people, they have spontaneous and hybrid use of both languages, and that it has a name, translanguaging. And there are lots of ways that we translanguage in regular life, but what happens I think is, again, going back to that ideology that is very prevalent in the U.S, which is monolingual is default, and even monolingual is superior is kind of part of the fabric, I think sometimes that we adhere to without even realizing it.

And so instead of lifting this multilingual perspective and the fact that we don’t have to be limited necessarily to one language or another, and we certainly shouldn’t make assumptions. And sometimes it’s a very different perspective where it’s not only a patient but maybe a patient plus their family member, and within them as a unit, they may have differences in their language preferences or how they prefer to express themselves. And so that should be accounted for as well.

I wanted to also kind of comment on one of the things that you said about how does expertise like linguistic expertise and cultural expertise get recognized? How does it get incentivized? And it always reminds me of also my days as a medical student and how I started doing this work as a student actually and teaching as a student. And so still, we see a lot of times where there may be this idea, well, if students are experts in this, then they can teach it. Let’s leave it to the medical student association to take charge of this. They can do a club for Spanish, or they can do a club for this. And I think there is an important distinction to be made there too, because yes, students come in with an expertise, they come in with a lived experience that’s super valuable, should be recognized and incentivized, and they have a right and a responsibility to professionalize those skills further and to receive that mentorship that you are discussing, seeking out that may not be present maybe at your own institution, but that’s maybe an opportunity to break those walls between institutions and identify mentors elsewhere, and so forth.

And I think sometimes, even if not within your same language space or cultural space, I think having that multilingual experience can be helpful to point out maybe some of those questions such as what you suggested of, hey, maybe you need to ask about language preference and rather than making assumptions, and those are some things that might be shared experiences or benefits across languages, even if we don’t have necessarily all the same shared languages.

Bright Zhou:

What our listeners are not seeing is me nodding emphatically, snapping. Yes! Yes! I 100% agree with all of that. And again, I’m just so excited because I’m recognizing this in of itself, this podcast in of itself is a space where we are reflecting on our bilingualism and our experiences, both as learners and as mentors. The last part about that vignette was just that I think I juxtaposed a traditional cultural humility interpretation of that story would’ve been, oh, you should have used an interpreter, or it would’ve been very simple. Okay, well, it’s either Mandarin or English. You can only choose one. And I think exactly as you said, we are coming to such nuances when we come together and reflect and realize that we have all of these other ways that we can be delivering health care that ultimately may increase our patient satisfaction and our patient adherence to our recommendations. And so there’s very real benefit and patient health impacts, and I just echo again, I’m just eagerly waiting for the actual evidence-based research to come out of that work to demonstrate the economic and health benefits of this, providing linguistically concordant appropriate care.

Debora Silva:

And that’s where I think that curriculum development comes in and formal teaching comes in. So even when you are speaking the same language, there are many words that are not the same in the different cultures. So you talk about Hispanic. Are you from Colombia? Mexico? Puerto Rico? La República Dominicana? We have so many different words, and there’s an expectation of our patients. So getting to the point of asking which language do you want to speak is really communication skills. But one thing is to teach communication skills in a monolingual world, and another very different one is to teach it in a context of language appropriate health care. So when I look at the frameworks that have been developed to teach language appropriate care, which are not many, one of the things that is very important, and you can see it in those that are doing the research, is the importance of teaching language appropriate care along with communication skills. It’s very important.

So when I say that here in Puerto Rico, we teach in both English and Spanish, we are teaching communication skills, and we are applying those communication skills to both languages, right? And the students are practicing it. And then 40% of my students go to the States, and they can take care of either English or Spanish speaking, and I hope that they can also self-assess their own proficiency. But we know that self-assessment is not enough, so that’s why we need to work towards best evidence in curricular development.

Bright Zhou:

I completely agree. I think just another example that supports that is in our course right now for clinical Mandarin, all of our students are heritage speakers, so they speak from home. But when we surveyed our class on what would be useful, no one knows how to do sexual health questions or mental health questions. Traditionally taboo areas where we’re not learning the words in our households. And then we come into medical education and we get some experience or frameworks for how to do sexual health histories and mental health histories, but we don’t have the space to not only learn the word, but I think all of us here can relate to practice how you might say it, what feels comfortable for you to integrate it into your own familiarity with the vocabulary. I actually had to learn the words myself before we taught it, on words like ejaculation, orgasm, sexual function, pleasure. And when you’re not even familiar with the slang word or the informal word, how do I distinguish between the official word, the medical word, and then the word that my patient might be using? It’s complex to be able to completely learn areas that I had never learned from my parents or from my community before.

And so just as another example, exactly what you’re saying, Debbie, I think we do need structure, and we do need curriculum in terms of not only the vocabulary, but how do we choose to communicate. I love that. How are we communicating very historically taboo or difficult to talk about languages? And again, this highlights that need for that mentorship partnership because it truly has to be another Mandarin speaker who can help me come up with the best ways that I can communicate sexual health questions, right? It cannot be anyone else. And so that’s just the need for our class and for our communities to create these curricula, so 100%.

Pilar Ortega:

And I’ll add as well to Debbie’s point about assessment, that I think this is an ongoing area of development and research, and we do have some of that currently in the collection that we curated in Academic Medicine, where there are a few articles that have looked at how do we assess the language skills of a physician or a medical student for language concordant care without an interpreter. And I think that is still something that is an ongoing area of inquiry and something that we need to continue as we develop further curricula and as we ask the questions that, like you mentioned, Bright, around what does it consist of exactly? What are the right words? How do we determine whether communication happened effectively?

These are not super simple. They’re complex questions. They may differ from one culture, one language to another. There may be some things that we need to further tease out within each of those to determine whether effective communication happened, which is ultimately the goal. And so that area of assessment and how we evaluate clinician learners, particularly when sometimes the faculty don’t have the skills in those languages to be able to determine that, right? So how do we seek that expertise out from maybe outside of the faculty? Are there opportunities for interprofessional collaboration? Are there organizations that maybe can help with some of those pieces but still have it be a medically contextualized evaluation, because we know language proficiency and medical language proficiency within that clinical context are different things? So I think there’s a lot of those things that are still in the works, and it is a really exciting area of further development that I think is worth investing further on, I think in medical education.

Toni Gallo:

So I want to open it up. Do you all have other questions for each other that you’d like to discuss? We’re having a great conversation, but anything else that you want to ask each other before we finish up?

Debora Silva:

So I do want to ask Bright, what are the next steps?

Bright Zhou:

So the next steps, I hear multi-layers to this question. I think the next steps for CRM is to carve spaces. At my institution here at Stanford, we’re trying to create spaces in the preclinical and clinical and even residency level stages to discuss what culturally reflective medicine might actually look like, to equip learners from the very beginning with these skills, or at least this acknowledgement that there are other people also thinking about these things and how might you find them and seek them out. And eventually, I think for CRM or anything, again it doesn’t have to be CRM, I think we’re already doing it, is to ultimately create structures that are compensated for the expertise of faculty and learners who use them.

I think the next steps for language in general, language in medical education, I would love to see … As we start to see more bilingual instructors and more bilingual clinicians and physicians, I would love to see some guided structure or requirements. Having a language requirement would be very interesting to consider for medical school entry. I don’t think everyone needs to learn the same language, but I think having an understanding of what bilingualism means and exactly as you said, Debbie, about how it enhances your communication skills would be very interesting to consider at a larger medical education level.

And then lastly, I think that there’s just so much interest. I think speaking specifically within family medicine as something that I know more closely, I think there’s just so much interest from our learners for this knowledge. I think all of us have spoken about, even before we were in medicine, all of our lived experiences with this. And so really, I think the next steps are just creating these structures that allow our learners to process all of these experiences that we’re having. And not only just creating a CRM, but making sure that we are still supporting our medical organizations, the social supports that are existing, making sure that if anything comes out out of these experiences that are particularly triggering, that there are mental health resources for students. All of the wraparound services that we normally would want for any of our patients undergoing potentially traumatizing experiences, I would want to make sure are available to students undergoing CRM. So I think those would be some next steps to consider.

Dr. Pilar Ortega:

I think those are great next steps, and I think it really highlights what I think is the core of the work that we’ve done in putting together this collection, which is really raising up language and culture to being an asset, to being a recognized asset and an attribute that helps learners, faculty, and ultimately patients to be healthier, to be happier and more fulfilled in their work. And I think that’s what we all want. We all have that shared understanding that we need to help learners reduce their burnout, improve their well-being, be better physicians, be motivated to take care of those who are underserved, and so forth. And I think language is an opportunity to do that in a way that really uplifts those who come in with lived experience that is super helpful and that already is a form of expertise.

Toni Gallo:

So before we sign off today, I’d like to give each of you … if you have any final thoughts you want to share with listeners about the work that you’re doing or where you think the field should go, the resources that are out there, I’ll give you each a chance. Debbie, do you want to start? And then we’ll go to Bright and Pilar.

Debora Silva:

So I think we have to start implementing what’s out there and it’s evidence-based. We have to start using the frameworks and applying them and researching. Instead of trying new things all the time, they’re already there, evidence-based frameworks and evidence-based curriculum that we all need to think about implementing it and helping each other, interprofessional or maybe the same profession but in different institutions, that we can collaborate to gather more data because we need the outcomes. And for that, we need to implement and measure. So that’s where I think our next steps are going.

Bright Zhou:

I 100% agree, and I welcome any listeners who are interested in this space. My concluding points about the linguistic appropriate care or linguistic concordance care is that it is ultimately what justice is, and it is ultimately an issue of diversity and inclusion. And so as our institutions continue to embrace diversity and equity and inclusiveness as part of their mission statements, I really want to echo the fact that language is a core element of that. And so investment in development of language is paramount to the continuation of JEDI work.

Pilar Ortega:

Great points, and it’s been such a pleasure to be on this podcast with all of you. I would add to that that we already know there’s an issue. There are health disparities related to language. We maybe need to focus a little bit less on the needs assessment portions of it because we know the need is there and we know how to fix it. Now, we really need to get into actually doing the work, lifting up those people who have the expertise, recognizing and incentivizing that expertise in order to move the field forward and really tie it to those outcomes in the long term. And I think really, a key part of that is data collection. So I would emphasize that we all kind of turn attention to our institutions as to what data is being collected about language. Are we tracking that in appropriate way that will permit further research and growth in this space? Which further can increase opportunities for our learners who come from those marginalized backgrounds who may be really motivated to take a look at that data and do something innovative with it.

Toni Gallo:

Well, I want to thank you all for taking some time to be on the podcast today. I appreciate the work that you’re doing, what you’ve done for Academic Medicine, and your contributions here today. So please, if you’re listening to this, look for Bright’s paper and look for the entire language equity collection on Academic Medicine‘s website, and look for the MedEdPORTAL language equity collection as well. There’s great resources there. So thanks everyone. Have a great day.

Pilar Ortega:

Gracias.

Debora Silva:

Hasta luego!

Toni Gallo:

Be sure to claim your CME for listening to this podcast. All you have to do is visit academicmedicineblog.org/cme, listen to the 8 episodes listed, and then follow the instructions to claim your credit. From the journal’s website, you can access the latest articles in our complete archive dating back to 1926, as well as additional free content like eBooks and other article collections. Subscribe to Academic Medicine through the Subscription Services link under the Journal Info tab, or visit shop.lww.com and enter Academic Medicine in the search bar. Be sure to follow us and interact with the journal staff on X, formerly Twitter, @AcadMedJournal and on LinkedIn at Academic Medicine Journal. Subscribe to this podcast anywhere podcasts are available. Be sure to leave us a rating and a review when you do. Let us know how we’re doing. Thanks so much for listening.