JUNE 2021 HEALTH WORKFORCE STRATEGIES by Diane Rittenhouse, Alicia Fernandez, FOR CALIFORNIA SERIES Alexandra Ament, and Janet Coffman Health Professionals and Patients in California: Speaking the Same Language California is facing a health workforce crisis. There are not enough health workers to meet the needs of the state's increas- ingly diverse, growing, and aging population. This Health Workforce Strategies for California series highlights current critical health workforce interventions and builds on the findings of the California Future Health Workforce Commission. C alifornia is facing a shortage of health profession- Although there are many languages spoken in California, als to meet the needs of its large, diverse, and the most prevalent after English are Spanish, Tagalog, aging population, and the situation is worsen- Cantonese, Mandarin, and Vietnamese.4 It is essential to ing. Shortages exist across professions and geographies, increase the number of health professionals in California with sizeable urban and rural underserved populations. who can effectively deliver health care services in a lan- Despite increasing population diversity, California's guage other than English. health professionals don't reflect the increasing diversity of the state's population. For example, in 2019, 39% of Currently, there are no data available on language profi- Californians identified as Latinx, but only 14% of medical ciency among California's health professionals. Physicians school matriculants and 6% of active patient care physi- self-report to the Medical Board of California the lan- cians in California were Latinx.1 guages they speak, but proficiency is not measured. Furthermore, the Medical Board data do not indicate whether a physician has sufficient knowledge of health Although there are many languages spoken care terminology to converse with patients in their own in California, the most prevalent after English languages about health care needs. are Spanish, Tagalog, Cantonese, Mandarin, This brief builds on a recent review of the evidence to and Vietnamese. identify long-term and near-term policy strategies to increase language concordance for health professionals Over the past two decades, studies have shown the and patients in California. importance of racial and social concordance between physicians and their patients as well as the need for inter- cultural competencies, which lead to increased trust and greater patient satisfaction. Particularly important, how- ever, is the ability to speak the same language, which not only increases trust and patient satisfaction but simultaneously decreases poor clinical outcomes due to Language concordance occurs when the health miscommunication.2 According to the US Census Bureau, professional and the patient are fluent in the almost 44% of California households speak a language other than English, and nearly seven million Californians same language and able to communicate (19%) report speaking English "less than very well."3 effectively about health and health care. Pipeline programs provide high school, college, and to ensure they can care for patients in that language.6 postbaccalaureate students with multifaceted support Upskilling heritage language speakers is ideal because to enhance their readiness for graduate-level health pro- they have cultural competence as well as linguistic com- fessional training and to help them successfully pursue petence, but enhancing the capabilities of people with health careers. Expanding pipeline programs that specifi- acquired language skills is also valuable. Intermediate cally enroll bilingual or multilingual students is an effective and advanced speakers need a relatively short period of long-term policy strategy for increasing workforce diver- training to be able to achieve competence at a level at sity that can also increase language concordance. These which they can care for patients who speak that language programs often provide academic, career, and psychoso- without an interpreter. Although Spanish should be the cial support as well as mentorship. Some programs offer highest priority given the large number of Spanish speak- financial support as well. Postbaccalaureate programs ers in California who have limited English proficiency, have been shown to be particularly effective at increasing grants should also be made available for classes in any the number of underrepresented students of color and Medi-Cal threshold language in the county in which a those from lower-income backgrounds who graduate health professions school is located. from medical school, choose primary care careers, and practice in medically underserved areas.5 Encouraging Another near-term policy strategy to increase language professional school admission processes to review appli- concordance is to provide ongoing state funding for cations holistically, especially taking into consideration the UCLA International Medical Graduate Program. the languages a candidate speaks, could also enhance This program began in 2006 with the goal to improve language concordance. health access to bilingual and bicultural family medicine physicians in underserved communities. The program Expanding specialized health professional school training admits Latinx physicians who have completed medical programs requiring a second language component, such training outside the United States but legally live in the as the University of California Irvine School of Medicine's United States, and prepares them for the US Medical Program in Medical Education for the Latino Community Licensing Examination while simultaneously providing (UC PRIME-LC) is another effective long-term policy hands-on clinical training and teaching them about the strategy for increasing language concordance. Although culture of medicine in the US. The program has several current programs are small, graduates obtain health care components and, on average, participants complete the training in two languages, directly impacting language program in one year. There is no cost to the physician concordance. while in the program, or for the examinations, and physi- cians also receive a small monthly stipend. The estimated average cost per physician to complete the program is Medi-Cal threshold languages are languages $55,000. In return, they agree to enter a family medi- spoken by 5% or more of Medi-Cal enrollees cine residency program in California, and then to work in a federally designated primary care shortage area in in a county. California for two to three years after residency, depend- ing on the amount of support they received during the Grants for specialized language training for intermediate program. Since the program began, it has graduated and advanced speakers of Medi-Cal threshold languages 160 international medical graduates who have gone on is a near-term policy strategy to increase language con- to family medicine residency training.7 These physicians cordance. Medi-Cal threshold languages are languages are uniquely positioned to care for the increasingly mul- spoken by 5% or more of Medi-Cal enrollees in a county. ticultural population in California and to help to diversify Many of California's existing health professionals are the current physician workforce. heritage speakers of a second language; others may have learned a second language in school. Both groups often require additional training in medical vocabulary California Health Care Foundation www.chcf.org 2 The Authors Endnotes Diane Rittenhouse, MD, MPH, senior fellow, Mathematica; 1. Alana Pfeffinger et al., Recovery with Limited Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity of California Alicia Fernández, MD, professor and associate dean for Medical School Matriculants, 1990 to 2019, Healthforce Center population health and health equity, UCSF; Alexandra at UCSF, December 2020; and Janet M. Coffman, Emmie Ament, MA, independent consultant; and Janet Coffman, Calimlim, and Margaret Fix, California Physicians: A Portrait of PhD, MA, MPP, professor at the Philip R. Lee Institute for Practice, California Health Care Foundation, March 2021. Health Policy Studies, UCSF. 2. Richard L. Street Jr. et al., "Understanding Concordance in Patient-Physician Relationships: Personal and Ethnic Dimensions of Shared Identity," Annals of Family Medicine About the Foundation 6, no. 3 (May 2008): 198–205; Lisa A. Cooper et al., "Patient- The California Health Care Foundation is dedicated to Centered Communication, Ratings of Care, and Concordance advancing meaningful, measurable improvements in the of Patient and Physician Race," Annals of Internal Medicine 139, no. 11 (Dec. 2, 2003): 907–15; Rachel L. Johnson way the health care delivery system provides care to the Thornton et al., "Patient-Physician Social Concordance, people of California, particularly those with low incomes Medical Visit Communication and Patients' Perceptions of and those whose needs are not well served by the status Health Care Quality," Patient Education and Counseling 85, quo. We work to ensure that people have access to the no. 3 (Dec. 2011): e201–8; and Alicia Fernandez and Eliseo J. Pérez-Stable, "¿Doctor, Habla Español? Increasing the Supply care they need, when they need it, at a price they can and Quality of Language-Concordant Physicians for SpanishS- afford. peaking Patients," Journal of General Internal Medicine 30 (Oct. 2015): 1394–96. CHCF informs policymakers and industry leaders, invests 3. "Limited English Proficient Consumers," State of California. in ideas and innovations, and connects with changemak- 4. "Languages in California (State)," Statistical Atlas. ers to create a more responsive, patient-centered health 5. Kevin Grumbach and Eric Chen, "Effectiveness of University of care system. California Postbaccalaureate Premedical Programs in Increasing Medical School Matriculation for Minority and Disadvantaged Students," JAMA 296, no. 9 (Sept. 6, 2006): 1079–85; Anneke M. Metz, "Medical School Outcomes, Primary Care Specialty Choice, and Practice in Medically Underserved Areas by Physician Alumni of MEDPREP, a Postbaccalaureate Premedical Program for Underrepresented and Disadvantaged Students," Teaching and Learning in Medicine 29, no. 3 (July–Sept. 2017): 351–59; and Herbert C. Smitherman et al., "Impact of a 50-Year Premedical Postbaccalaureate Program in Graduating Physicians for Practice in Primary Care and Underserved Areas," Academic Medicine 96, no. 3 (Mar. 1, 2021): 416–24. 6. Lisa C. Diamond and Daniel S. Reuland, "Describing Physician Language Fluency: Deconstructing Medical Spanish," JAMA 301, no. 4 (Jan. 28, 2008): 426–28. 7. "International Medical Graduate (IMG) Program," UCLA David Geffen School of Medicine. Health Workforce Strategies for California Series  |  Health Professionals and Patients in California: Speaking the Same Language 3