Language Concordant Care: Pilar Ortega MD on Multilingual Physicians

Rivka Allouche (00:08)
If there is one department where language access is needed instantly, it's the emergency room. Second counts, communication has to be clear, fast, and accurate, especially when patients and providers are navigating language barriers in high stakes situations. But the ER is only where the challenge is most visible, the bigger question is what it takes for patients to receive care directly in their own language from clinicians who are prepared to provide it safely. I'm honored today to welcome Dr. Pilar Ortega, a physician and leader with extensive experience in emergency medicine and medical education. She is president of the National Association of Medical Spanish and CEO of the Center for Clinician Multilingualism. We'll start on the front line, in the ER and then dive into Pilar's research on language concordant care: how many new physicians are multilingual, how we assess whether clinicians' medical language skills are ready for patient care, and the role language access plays in the professional identity of Latinx medical students and residents. We'll also look at the solution NAMS and the Center for Clinician Multilingualism are building. And where AI medical interpreting fits alongside clinicians to make sure every patient in every encounter can be understood. Pilar, welcome to Care Culture Talks.

Pilar Ortega (01:30)
Thank you so much. I'm really excited to be here.

Rivka Allouche (01:32)
Thank you very much. So I will start with the first question. Can you tell us about your background and what drew you to language access specifically in healthcare?

Pilar Ortega (01:42)
Yes, absolutely. well, my background as a professional is as an emergency medicine physician, as you mentioned, but my background in language access started when I was a child because I am part of a family where Spanish is spoken at home. As the youngest person in my family, I was the one who had the most experience with English. So I was often helping my family navigate things both related to school, for example, legal matters and healthcare matters. In that process I realized that over time that the skills that I had by being a multilingual person was extremely helpful to my family's own healthcare. Of course, it's a position I should never have been in as a child, and yet we still know that that happens every day in the United States. So as I pursued further education, as I finished high school and then went to college, I was able to notice things that maybe others didn't notice because of the lived experience that I had with my own family. I realized that the skills that I had are something that I could share with my peers. So I started creating, you know, student groups, different opportunities for people to advance their own skills, whether it be in Spanish or whether it be cultural knowledge about the communities we served. And then when I decided to pursue medicine, it all flew, you know, was flowing from that same background that I had with a passion for language access. And so I was building that into my own education, my own training. And that's how I developed, you know, courses and things to help other people, resources to help other people who were also on the pathway to becoming a physician, to be able to improve their own skills and take excellent care of all of our patients regardless of their language preferences.

Rivka Allouche (03:38)
So when you started, were you like we read in the literature the bilingual clinician that people would call to help interpret or to help facilitate the encounter?

Pilar Ortega (03:49)
It happened to me a lot as a student. Yes. In fact, one of my first experiences as an undergraduate college student when I decided to look into how I could get involved in this space. There wasn't a actually a lot happening at that time in terms of training opportunities for me as an undergraduate student, but there were volunteer opportunities at local hospitals, at free clinics for patients who had limited economic resources. So I volunteered at one of these clinics and I immediately, because of my Spanish skills, I was immediately very helpful in the clinic. And one of the ways that I was asked to help was as an interpreter. And at times I was in situations where patients were sharing things with me. They had never shared with anyone before traumatic things that may have happened to them just because I was the first person that they had met that understood them in their language. So they were sharing that with me and I was immediately, out of my depth because at that time I'm a college student, I have no medical expertise whatsoever. So I was resourceful though and was able to get them connected to the care that they needed as much as I could. But we're often put in these tough spots just because you may think a visit is going to be very simple or something like that. I see students still being pulled to be ad hoc interpreters for their peers or for their supervisors at times because they happen to speak the patient's language or supposedly, right, they have the skills. But A, those skills may not have been verified, B, they're probably not actually trained as an interpreter. And it really puts them in an unfair situation, because you're quickly out of your depth and you may not be able to handle, everything that is coming your way just because you have some skills in that language.

Rivka Allouche (05:39)
So for you, what is language concordant care and why does it matter for patient outcomes?

Pilar Ortega (05:45)
Well, thank you for that question because I think one of the things that people often kind of don't fully understand is when we talk about language concordant care, is that the same thing as language access? Is it the same thing as interpreting? and no, the answer is no. The these are different concepts and so what I would say how I define language concordant care is when there is a shared language between the clinician and the patient. Assuming, that there are two people in this interaction. This gets more complicated when there are more than two people in the interaction, which there often are, right? Families are part of a patient's care oftentimes and there may be differences in language preferences between family members, for example. Also, team members are more than just one clinician. So usually, you know, I work at a teaching hospital, we have residents, we have faculty, we have medical students, we also have additional staff, of course, who are critical to our patients' care, beyond physicians. The healthcare team is also not monolith in terms of language skills. So it quickly becomes more complicated than that, but the basic definition of language concordance is having a shared language between the individuals. I do want to emphasize though that it's not just a matter of the proficiency in the language, it is the ability to negotiate meaning between two people with a shared language. So sometimes, we've all probably been in conversations with somebody with whom we presumably share a language, let's say, English, for example, a and yet somehow we're not communicating. Something is, not really being understood or I'm not explaining myself properly. Language concordance does go beyond just do you have the skills in the language itself? It's how well are you able and in a healthcare context, we're talking about language concordance in a very specific way. It's within that healthcare context.

Rivka Allouche (07:42)
Let's say that we are talking about a pool of three hundred languages, how do you see that health system could implement those languages into their staff or if it would be in-house interpreters or actually clinicians?

Pilar Ortega (07:56)
It really is a combination of approaches and strategies to language access that we need to take. Because as you said, there are over three hundred fifty languages spoken in the United States. Just the volume of that alone, there will always be patients with whom we don't have a shared language as a clinician workforce in a particular setting. And so we definitely have to be prepared. We have to have ways to communicate appropriately with all of our patients, regardless of their language needs. And I think we can also mobilize additional strategies in addition to having interpreters available. which include language concordance strategies and that's because many of our clinicians do speak languages besides English and so we know from the research that I've done that actually for physicians, which is where I've done most of my research and where most of the published literature has studied this particular part of the workforce and we need more research by the way in health professions like nursing, a pharmacy, physical therapy, I could go on and on about all of the needs and research. But for physicians, I can tell you that almost three quarters of incoming resident physicians who are starting as they just graduated from medical school, they're starting their specialty training, they report skills in at least one language besides English. So and that is across levels, but that's the majority of our physicians are reporting some amount of skills in a language other than English. There is something there, there's an asset there that we are not currently really maximizing its impact. So I think it's critical that health systems evaluate what are the languages that are preferred by their patient population, and is there an opportunity to consider, the language skills of a staff, you know, when you are recruiting.

Rivka Allouche (09:50)
Their resource.

Pilar Ortega (09:51)
Yeah, Exactly! When you're recruiting residents, or when you're recruiting physicians or when you're recruiting nurses, et cetera, they should know what are the languages of the patient population and then what are the language skills of the people that you're recruiting that would be most helpful to provide the best quality, most efficient, and effective care to your population.

Rivka Allouche (10:10)
Indeed, and I read that the results, the care results are better when people feel understood and trust through the language. I had another question, more related to your experience in emergency medicine. Can you share one or two moments that you have in mind when language access was actually really a barrier and changed the course of care?

Pilar Ortega (10:30)
Absolutely. We see this every single day. I can share, maybe two stories that come to mind. So one is at times people are using the emergency department. they come to the emergency department with a concern that maybe if they had had appropriate language access previously, they may not have needed to go to the emergency department at all. An example of that is when somebody has a concern about how high their blood pressure reading is, but the problem was that they didn't understand how to use the blood pressure cuff, how to appropriately measure it, when they need to seek care, how dangerous a certain blood pressure measurement is what to do about it, who to contact. So that's an example of somebody, legitimately believing that they are having a medical emergency, but if they had received appropriate education on how, when to measure, who to call, and been able to do that in their own language, they may not have needed to wait for six hours to be seen. All of the things that happen when you go to the emergency departments and maybe that was not the best use of your resources, your time, and so forth. Maybe they get some unnecessary tests, and so on and so forth. That is one example and then of course you have also patients who come in with some kind of severe presentation. Let's take for example a patient coming in with a change in their mental status. So they are not thinking clearly, they are not able to express themselves the way they would normally be able to express themselves. In that moment, we in the emergency department patients go through a process called triage; where we determine the acuity, how urgently the patient needs to be evaluated by the physician. It in that moment it may be very difficult to determine whether what is happening is related to actual change in their cognitive status or is it that they're not able to communicate due to language. Are they being offered language access in that moment when they're being triaged? It's a very sensitive moment for determining how acutely somebody is going to be seen. And it can result in delays because if somebody is mistriaged as not really being an emergency because it's just that just i you know, in quotations, right? Just that the language did not permit us to communicate appropriately, then you might be talking about a patient who maybe had a stroke and instead of being eligible for, all of the treatments that have to happen within a certain amount of minutes that they presented, they are not no longer eligible because by the time they were seen, a few hours later, they're no longer within the time window where we can offer all of the potential treatments for that problem. These are, things that come up all the time in the emergency department. Sometimes they can be a life and death situation for patients.

Rivka Allouche (13:27)
So what you say reminds me of what I read in one of the paper on the JAMA Network paper. So you said that sometimes physicians underuse professional interpreters and I couldn't understand why. Would you have some explanation why it happens?

Pilar Ortega (13:42)
It's very complicated when you're actually in the moment of having a patient in front of you. Let's say you've determined that that patient has a different language preference from a language that you speak. Why would you not use an interpreter? Well, it's a very complex situation especially from my vantage point in the emergency department, there is a significant time pressure oftentimes with what's happening with a patient. You need to act quickly. In that moment. It may be if you have partial skills in a language, it might be tempting to use some of those partial skills if that you have in the language to quote unquote get by to do the initial assessment. If the patient came in with a family member this happens a lot. You might be tempted to have the family member be an ad hoc interpreter. This is something that we also see a lot. Many health systems have made great strides in increasing accessibility of interpreters through for example video remotes interpreting capabilities and interpreters, people can access through their own phone device. These do increase accessibility but one thing that we haven't done so well is teaching clinicians how and when to effectively partner with an interpreter because sometimes when the access is there, I mean that is a big you know, a big, big factor. So that helps. But if a clinician really thinks they can get by, even the minute or so that it would take to connect to the device is too much, they may get by without it. For those, you know often complicated systemic reasons and then sometimes it's a culture thing too. If at some places it's not part of the healthcare culture that we always offer working with an interpreter, then that can become a barrier in itself for some clinicians to practice. Where I work, we do have a culture of working with interpreters and my colleagues and I will always prioritize, working with interpreter and offering interpreter as needed. And one of the things I always teach my students and residents. If you need one in a situation, the interpreter is also there to help us as the clinician provide the best care possible. The interpreter is not only there for the patient, the interpreter is also there for us.

Rivka Allouche (15:59)
For the provider.

Pilar Ortega (15:59)
Yes, to be able to communicate effectively. So of course, if you are qualified to use your own language skills to directly communicate with the patient, again, that's language concordant care, that's the best solution. That direct communication has benefits for health outcomes, for trust, for satisfaction, and so forth. But we don't speak all the languages that our patient speaks, so we definitely need to know how to partner effectively with interpreters as well.

Rivka Allouche (16:26)
Indeed. And to go back to the study, and I think it was very encouraging, out of a hundred thousand first year residents, more than thirty seven percent reported advanced and native proficiency, in a language other than English. So for me it was encouraging. What does it mean for patients?

Pilar Ortega (16:42)
Yes. I think that is one of the kind of take home points that I like to emphasize as well because is sometimes health systems or health systems leaders may have the idea that clinicians don't tend to speak additional languages. But this is evidence that that's not the case. We have a three quarters of physicians who speak at least some of a language, that means that's an opportunity to further enhance those skills, right? and at least to use those skills to build rapport with the patient, even if they have to work with an interpreter for certain aspects of care. And then for those as you mentioned, like 37% who report advanced or higher skills in a language, that means that they are likely to pass a formal test as a language concordant clinician. And I think it is important to make the distinction that from that study we have data based on self-assessed proficiency. So we know self-assessment is not perfect. And so we recommend, especially when you're in training, you haven't had as much experience yet in clinical care, you really should be trained and tested before you determine or confirm your qualification as somebody who can provide language concordant care in a particular language. But absolutely it's very encouraging that such a large percentage of incoming resident physicians in the study had advanced or higher skills in at least one language other than English.

Rivka Allouche (18:08)
And where I wanted your feedback as well is like Spanish, Tagalog, Vietnamese and Chinese are among the most common patient languages, yet have some of the lowest numbers of physicians who speak them. How would you explain that gap? I was pretty surprised for Spanish. I would have assumed that it's the bigger number of clinicians and interpreters.

Pilar Ortega (18:30)
It actually is. So Spanish is the most common language other than English reported by clinicians but because it is also by far the most prevalent language spoken in the United States, besides English, that prevalence in the general population far outpaces the prevalence of Spanish spoken in the physician population. So because of that, Spanish is one of the most underrepresented languages in the workforce relative to its frequency in the patient population. The same thing happens for the languages you mentioned of Vietnamese, Tagalog and Chinese, which from the data we had, we know Chinese languages are many and varied and include Mandarin and Cantonese among many others, and it's not disaggregated. So that's something, that in the future hopefully we can also get more better data on that so that we can better target initiatives to improve the physician language concordant workforce.

Rivka Allouche (19:28)
And do you see an interest from your students, knowing more about languages and culturally competent care? Are they asking questions? Do they want to improve in that area?

Pilar Ortega (19:38)
Yes, there it actually there's a huge demand for language education. many students go into medicine, students who come in with some prior language skills, they specifically want to gain these skills. so they often are looking at medical schools, evaluating what type of programs they are offering to help them become the bilingual physician they want to become. I do see that also as very encouraging because this generation of medical students are very focused on getting the skills that they feel they need to achieve their goals of taking care of the communities they want to care for. So we I think as a medical education system, we do have a responsibility to keep that fire and passion that they come in with with the desire to take care of these communities, and give them the skills they need to do that effectively, to provide the best quality care. Sometimes, people can be a little bit discouraged. So they can come into medical school with these like big hopes and goals and even choose a school because they're gonna get this education. And then they might get some mixed messages, that sometimes this happens during training or they might get pulled in different directions. We want to make sure that we have enough programs there. There is so much work left to be done. I'm an academic, so I of course want students to also pursue research. I want them to ask questions. questions that we can answer through research. I want them to be a part of these solutions because I think that's how we advance as a field. So I am really, really proud that over the past 20 years and we recently did a review of how far have we come in medical Spanish education, how many more publications do we have now than we had 20 years ago. And it's really cool to see how much the field has grown, from scholars all over the United States, some international journals and scholars as well have published on this topic because obviously, this is an issue not just in the United States, it's a global issue as well. And so it's been wonderful to see the impact, that one publication will lead to more and more and more people getting involved in the field. It's great to have a way to mentor students and support them through this is your passion to begin with. We want you to take that passion, all the way through your career.

Rivka Allouche (22:03)
And I also think the industry is also supporting this enthusiasm because like in our perspective we don't only have Spanish, we do have Mexican Spanish, Dominican Spanish, Spanish for people from Puerto Rico. So we know that it's not even, the big label of Spanish and we need to go granular and to respect every nuance that we can. So I think there is something that is changing and it's again very encouraging.

Pilar Ortega (22:27)
Yes. I think as far as the richness and varieties of Spanish, yes. I mean it is one language, but as you said, there are nuances, sometimes even just within families, you know, people make up words, people have, you know, so this is very common. And of course this is not only in Spanish. Many languages of course have this rich varieties. but Spanish is spoken across the globe and there are many different not only the accent, but sometimes the words, sometimes the grammar is variable across the way that Spanish is spoken across the world. And that's beautiful. And all varieties of Spanish are equally valued and or ought to be equally valued and respected and absolutely teaching learners to communicate with all patients of all varieties of Spanish and how to figure out if there is something you don't understand how do you negotiate that? How do you figure it out? and knowing where your language supports are too if you need help, are really important skills.

Rivka Allouche (23:23)
Your Academic Medicine paper describes two ways to provide language appropriate care. So one that I noted was the professional interpreters like we talked about and language concordant clinicians. So how should health systems decide when to use each?

Pilar Ortega (23:40)
Well, I think health systems have to understand that both have to be a part of the solution. At the end of the day, clinicians do have to have some autonomy in determining when it is the appropriate time, but it should be guided. So what I mean by that is that there should be a way that a clinician can verify whether they have the skills in a particular language to provide language concordant care. And if you have a formal and validated way to verify those language skills, then that clinician is able to use that language directly with patients. And of course, all clinicians who have been verified need to know that if they need help, how they can obtain it, because like I said before, even if I'm speaking the same language as the patient, sometimes there is something that is I'm perceiving there is some barrier to communication. There's some reason we're not understanding each other. I may need some support in that situation. And it's not necessarily a linguistic issue, but it might be. So I think that's something we always like in emergency medicine. We get consults, right? We consult with other specialists when we need help with a particular problem or the patient needs a specialist. So I think we need to think the same way about communication. And sometimes if there's something that's not going well, we need to know how to address it. So the key for health systems is that they there needs to be a pathway that is standardized. That's one of the things that at the Center for Clinician Multilingualism we have worked on and we have a toolkit that's a resource on our website that anyone can download and access. It has recommendations for how do we determine whether this particular clinician it needs to have a verification exam done or if they just need to use an interpreter all the time. So there is a decision pathway that you can follow. That I think makes it a little bit easier to understand. Well, it's not that we need to test every single clinician, but there are some that we may need to test, verify their skills, and there are others who maybe we say, you always will need to work with an interpreter and maybe give them access to a course to advance their skills if they are interested in doing that in the future.

Rivka Allouche (25:58)
So we spoke about health systems and most probably organizations that have the most resources. We are also in touch with safety nets and free clinics like we talked about earlier. They need to prioritize maybe and I'm not even talking about concordant care. I'm talking about language access. Which recommendation would you give for them to start with language access? Maybe does it start with a number of languages or having bilingual staff? How would you start with that?

Pilar Ortega (26:25)
I do think at the end of the day, recruiting a language concordance staff is the best way to go for any institution, right? If you know what languages are spoken primarily by your patient population, you know, that should be one of the guiding principles, I think, in determining your language access plan. I think the other thing that can be really helpful because as you said, resources are limited and is especially more so in some places than others, right? So doing an assessment of what your current workforce capacity is in terms of their language skills, that will be helpful as well because what has happened historically is we kind of ignore the clinician workforce language. Nobody has ever asked or maybe it's just something they put in as a hobby or something, what languages they speak or something like that. So it has not been treated as a professional workforce skill but if we do that, then we can get a much better understanding of, why is the interpreter utilization low in this department? You know, is that a problem? Like what's happening with our just patient safety issues that maybe are coming up in this part of the hospital or in this situation, are they related to communication or are they not? Well, it's very hard to even do like an assessment of what's happening if we don't even have the data. So I think having an assessment of your current workforce capacity, considering language of your population in future recruitment, I think can be really important steps for especially low resource, but really all institutions.

Rivka Allouche (28:04)
Thank you very much. And you've worked with in-person interpreters and on the phone. You said earlier video and so telehealth. What modalities work best? Because I read a lot about telehealth and all the platforms are in majority in English. What would you say on that tools?

Pilar Ortega (28:21)
I would emphasize that the most important thing is working with a qualified interpreter. The modality I think matters a little bit less, but there are certain exceptions. So in the emergency department where I work clinically, it is the ideal to have somebody in person and part of the reason for that is that you want that immediate access so if you have somebody who you can overhead page and can come to the room where you are and is accustomed to emergency interpretation in emergency setting it can be very very helpful you also have a chance to it usually in these types of emergency departments who are lucky to have in person interpreters you get to know them also. So I think that allows for a very nice collaboration and teamwork. I which is it should be, we should recognize our interpreters as critical members of the healthcare team. So having them be there in person definitely facilitates getting to know them like we do the rest of our staff. So I think everybody prefers an in-person interpreter if possible. They're able to read the room a little bit more, they can help navigate this. But I think it sometimes it doesn't go great if the clinician has never been taught to work effectively with an interpreter. So you can sometimes go get into the situation where the clinician is speaking to the interpreter instead of speaking with the patient, for example. Very basic things, but if we're not taught how to appropriately navigate these encounters, they can definitely become problematic. I would say the in-person interpreter is also very helpful when there's more than one person in the room, it's loud, maybe you have a trauma situation where you have literally like more than 10 healthcare team members in the room at once. The environment can be very challenging if you were to have a phone speaker phone for example or even a video interpreter it's very challenging to position so that both you can hear the interpreter and that the interpreter knows what's going on and can see who's speaking it's extremely extremely challenging so I think for those types of situations really highly prioritize in-person interpreting and then there are some specialized situations as well where you really need interpreters who understand that situation. For example, psychiatric interviews are very challenging to do across languages. So that's another example of a situation where I would say having someone who has special skills in that area and ideally who could be in person could be very helpful.

Rivka Allouche (30:55)
Exactly. You illustrated what we call here the beauty of the human brain. So we come here with a machine that is able to interpret, but at the end of the day the human brain has the ability, to see how many people, how many voices in the room and knows who to talk to and what to interpret. But I wanted to ask you about the scaling language access or scaling care equity and I wanted to bring to the conversation AI interpreting and I wanted to know if you had something to share with us if you already tried AI interpreting. I would say medical AI interpreting, not maybe a consumer like Google Translate. I know that could be used, but a dedicated tool for interpreting.

Pilar Ortega (31:36)
Yeah, no, I have not. I have not used that. I think it's something that obviously there is exploration and I think there is study that remains to be done about it. There are definitely ways that I can see AI being a valuable tool in language teaching. Some of the courses that we use. We've incorporated AI in various ways because I think it can be a really great tool for practice, feedback, et cetera, for our learners. So that's something that I do have more experience on in terms of the role of AI in trying to scale some of the educational initiatives that we have. So I definitely see a value to that.

Rivka Allouche (32:18)
And what is at NAMS working right now? Are there projects you want to talk to us about or what we should expect for end of twenty twenty six, twenty twenty seven?

Pilar Ortega (32:28)
Yeah, sure. So the National Association of Medical Spanish is which is the nonprofit organization that I started a few years ago really because I knew there were other people working on medical Spanish, but we really didn't have a way to kind of create a network that we could collaborate together, do research together, and also to create a forum where we can present our work and advancements in the fields and learn from each other. So we do have our conference coming up. We have our national conference taking place in Huntington Beach, California, November 12th through 14th. It's coming up very soon. Our team is very, very busy getting prepared for that. And we are, just super excited to welcome all of our members. This is our one like in-person event every year where we have students through faculty from language fields, from health professions, different disciplines coming in to share what they've been working on, the latest research. We have posters, we have oral presentations and so forth. That's our most exciting event coming up very soon.

Rivka Allouche (33:32)
Congratulations. Would you have a final word to share with all our audience, either vendors or providers, health systems about providing care for all.

Pilar Ortega (33:43)
I would say, language is a wonderful asset that both our communities bring, that enrich our lives when we meet people, and that they can share their stories, and that language is an asset that our clinicians bring to the table too. So I feel very, very lucky that I've been able to like build my career around something that I'm so passionate about and that I see there's a big ground as well in general, with lots of companies, institutions, and individuals getting excited about making language access a priority. So it's really been a pleasure to be here with you talking about these topics.

Rivka Allouche (34:23)
Thank you very much. It was awesome. I had the opportunity to talk to doctors, providers, vendors and to be one step before to understand more about the research and the global picture is amazing for us, to move forward. So thank you very much.

Pilar Ortega (34:39)
Thank you so much for having me.