Language Concordance: The Missing Pillar in Patient-Centered Communication 

Focus Area:
State Health Policy Leadership
Health Equity Social Determinants of Health
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Patients who speak English go to the doctor’s office in the United States expecting to communicate with the health care team in their preferred language. For at least 25 million US residents who have a non-English language preference, this expectation is often left unmet.*  

Ours is a country in which the vast majority of the physician workforce does not speak the most common non-English languages spoken, such as Spanish, Chinese, Tagalong, Vietnamese, and Arabic. We know that language concordance, in which a health professional and patient speak a shared language, improves clinical care and patient outcomes, like improved glycemic control in patients with diabetes. Yet the US health system chronically underinvests in interpreter services and available services are often underutilized. In our clinical training, we have often encountered situations in which health professionals do not access available professional language services for patient care, actively deepening health inequities. Language is therefore a social determinant of health.

Driving Deeper Health Inequity 

Imagine this. In Room 001, “Luke” is sitting in his hospital bed with his silver hair combed back. When the oncology team walks in, he explains that combing his hair every morning helps him feel dignified through the days lying in a hospital bed. The attending physician on the team pulls up a chair next to Luke and carefully explains that his metastatic cancer is no longer responding to treatment and it is time to escalate care or consider hospice. Luke chooses to go home on hospice care. In contrast, in Room 002, “José” is sitting in his hospital bed. José’s preferred language is Spanish. His cancer is also not responding to treatment. Due to the perceived time constraints of using an interpreter, the team does not pull up a chair to have a goals-of-care conversation. “We’ll come back this afternoon,” they said through the medical student they used as an ad hoc interpreter. José’s condition worsened. He became unresponsive and died later that day without the opportunity to have an end-of-life care conversation with his care team or his family.  

This real-life scenario, which one of us observed, is a singular example of how clinicians may spend less time with patients with non-English language preference. Evidence shows that clinicians conduct fewer bedside pain assessments with these patients and a majority forgo professional interpreter use. In addition, patients with non-English language preference experience different outcomes at the end of life, with delays in transition to comfort care and higher rates of unilateral do-not-resuscitate orders.   

Legal Mandates Largely Unenforced 

The difference in experience between patients with English and non-English language preferences is so stark that it is reasonable to ask if it is even legal. In short, no, it is not legal. Title VI of the Civil Rights Act of 1964 – later reinforced by Executive Order 13166 – requires that all healthcare facilities that receive federal funds offer free, competent interpreter services when needed. Further, Section 1557 of the Affordable Care Act of 2010 extends these protections to health-related programs. Despite these mandates, there are few measures of accountability. New policies should be implemented at state and federal levels to require more robust reporting of professional interpreter availability and use and health care worker language skills validation. Future public funding levels should be allocated contingent on meeting established language access standards in reports. The 2023 U.S. Department of Health and Human Services Language Access Plan also calls for more robust reporting structures for individuals to report poor access to language services from institutions receiving federal funds.  

The Cultural Shift Begins in Medical Education 

Language-concordant care should be recognized not only as a legal requirement for all, but also as a quality and safety measure and part of a clinician’s ethical obligation to offer dignified care. This requires expanding our concept of patient-centered care and communication and the way they are taught to health professions students. Patient-centered communication is a skill that requires intentional practice by clinicians and clinicians-in-training, and language concordance must be a central pillar.  

Currently, undergraduate medical education focuses on mastering effective communication, but communication with patients whose language preference is not English falls flat. As trainees, we learn to take careful histories that lead us to a constellation of symptoms and diagnosis. We learn to be intentional in word choice, always “inspecting and examining” rather than “looking and touching” the patient. We learn to use the teach-back method to ensure that the patient has understood their diagnosis, treatment plans, and medication instructions. We learn to break bad news in a sensitive, empathetic, and effective way, like pulling up a chair to share that any further treatment is medically futile. We learn to build rapport through small human interactions, like talking to a patient about doing their hair before morning rounds. But when it comes to speaking with patients with a non-English language preference, we are often left to our own devices.  

Improving communication between patients with non-English language preference and their physicians demands a significant cultural shift, medical education prioritization, and policy change. First, we must recognize language as an important determinant of health that affects patient outcomes. Second, the medical education continuum from undergraduate to continuing medical education must prioritize patient-centered communication that includes physician language skill development, and the effective use of medical interpreters. Third, health care institutions must invest substantially in language services, such as in-person interpreters, professional language lines, and advanced language technologies, and also provide comprehensive training to staff on accessing these resources. 

Health policy should incentivize language-appropriate communication in health care settings by ensuring, for example, that language services are appropriately reimbursed by all insurers in all US states to account for the time, technology, and personnel needed and additional complexity of care. Additionally, accreditation and government bodies should create measures of accountability. These changes would affirm the inherent worth and dignity of every individual, regardless of the language they speak. As the country grows more linguistically diverse, we need to ensure our health care systems are equipped, and our clinicians are trained, to deliver patient-centered, language-concordant care. 

*We have opted to use the more encompassing term “non-English language preference” in lieu of the historically used “limited English proficiency” to recognize the spectrum of patients and health care circumstances in which language use preferences might differ.