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Research Letter |

Non–English-Language Proficiency of Applicants to US Residency Programs FREE

Lisa Diamond, MD, MPH1; Douglas Grbic, PhD2; Margaux Genoff1; Javier Gonzalez, MFA1; Ravi Sharaf, MD, MS3; Collins Mikesell, MA2; Francesca Gany, MD, MS1
[+] Author Affiliations
1Immigrant Health and Cancer Disparities Service, Memorial Sloan Kettering Cancer Center, New York, New York
2Association of American Medical Colleges, Washington, DC
3Northshore/Long Island Jewish Health System, New Hyde Park, New York
JAMA. 2014;312(22):2405-2407. doi:10.1001/jama.2014.15444.
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Published online

More than 25 million US residents have limited English proficiency, an 80% increase from 1990 to 2010.1 Limited English proficiency (LEP) may impede participation in the English-language–dominant health care system.2 Little is known about the non–English-language skills of physicians in training. This study characterizes the language diversity of all US residency applicants through the Electronic Residency Application Service and contrasts applicant language skills with the predominant languages of the US population with LEP.

Applicants were asked to self-report proficiency in all languages spoken using the Interagency Language Roundtable scale adapted for physicians for the first time in 2013.3 The 5 response options were: “native/functionally native,” “advanced,” “good,” “fair,” and “basic.”

We explored the percentage of applicants who were English-speaking only vs those who reported more than 1 language by ethnic self-identity and citizenship/immigration status. The applicants’ linguistic diversity was contrasted with the US LEP population. The top 25 LEP languages spoken were obtained from the US Census Bureau for individuals aged 5 years and older between 2007 and 2011.1 The US Census categorizes individuals as LEP if they report speaking English less than “very well.” The prevalence of at least advanced proficiency among applicants per 100 000 LEP speakers was calculated.

We used logistic regression to calculate odds of reporting non–English-language proficiency (Stata version 12; Stata Inc). We considered a 2-sided P value <.05 to be statistically significant. The Memorial Sloan Kettering institutional review board decided that the project required neither monitoring nor applicant consent because the data were deidentified.

Most (84.4%) of the 52 982 applicants for 2013 reported some proficiency in at least 1 non-English language. The most common languages were Spanish (53.2%), Hindi (20.5%), French (15.6%), Urdu (10.1%), and Arabic (9.8%). Of applicants with any non–English-language proficiency, 48.1% reported native/functionally native proficiency; 10.8%, advanced; 11.8%, good; 10%, fair; and 19.4%, basic. Only 21% of applicants reported at least advanced Spanish proficiency. More than 95% of Latino applicants reported speaking some level of Spanish, frequently with native/functionally native proficiency (84.5%).

Compared with white applicants, Latino (odds ratio [OR], 27.3 [95% CI, 19.9-37.6]), South Asian (OR, 18.2 [95% CI, 15.8-20.9]), and other Asian (OR, 8.6 [95% CI, 7.5-9.8]) applicants were more likely to report speaking 2 languages (P < .001). In addition, compared with white applicants, Latino (OR, 19.4 [95% CI, 18.2-20.6]), South Asian (OR, 3.4 [95% CI, 3.2-3.6]), other Asian (OR, 1.2 [95% CI, 1.1-1.3]), and black (OR, 1.2 [95% CI, 1.1-1.4]) applicants were more likely to report speaking 2 or more languages (P < .001). Non-US citizens were more likely to report proficiency in 2 or more languages (Table) compared with US citizens (OR, 6.9 [95% CI, 6.3-7.6], P < .001).

Table Graphic Jump LocationTable.  2013 Residency Applicants by Ethnic Self-identity and Citizenship/Immigration Status

Among the 25.1 million US LEP speakers, 16.4 million speak Spanish.1 For every 100 000 US LEP speakers, there were 105 applicants who reported at least advanced proficiency in a non-English language. Relative to this rate, there was an overrepresentation of Hindi-speaking applicants, and an underrepresentation of Spanish, Vietnamese, Korean, and Tagalog, which are 4 of the top 5 US LEP languages (Figure).

Place holder to copy figure label and caption
Figure.
2013 Applicants With at Least Self-rated Advanced Proficiency in a Non-English Language in the United States

The data presented in this figure are from the US Census Bureau.1 The following categories, which were among the top 25 languages, were excluded: other Indic languages, African languages, other Asian, other Indo-European, other Pacific, and other Slavic. LEP indicates limited English proficiency.

aIncludes Cantonese, Mandarin, and other dialects.

bRefers to all LEP speakers in the United States; therefore, in 2013, there were 105 applicants with at least advanced proficiency in any non-English language for every 100 000 LEP speakers.

cThe US Census Bureau combines both Spanish and Spanish Creole.

Graphic Jump Location

Even though applicants for medical residencies are linguistically diverse, most of their languages do not match the languages spoken by the LEP population. Further research is needed on whether increasing the number of bilingual residents, educating trainees on language services, or implementing medical Spanish courses as a supplement to (not a substitute for) interpreter use would improve care for LEP patients.4,5

This study has limitations. The data were based on self-report. However, a recent study found that clinicians’ self-assessment correlated with their oral language assessment, particularly at the high and low ends.6 Fifteen percent of applicants did not provide a self-identity and only 26 392 (49.8%) matched into an internship. The population actually entering internship may differ in their diversity or language proficiencies. Because of confidentiality, we do not know the relationship between applicant language proficiency and geographic matching of these skills to the local communities’ language needs.

Section Editor: Jody W. Zylke, MD, Deputy Editor.

Corresponding Author: Lisa Diamond, MD, MPH, Immigrant Health and Cancer Disparities Service, Memorial Sloan Kettering Cancer Center, 300 E 66th St, New York, NY 10065 (diamondl@mskcc.org).

Author Contributions: Dr Diamond had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Diamond, Grbic.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Diamond, Grbic, Genoff, Sharaf.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Diamond, Grbic, Mikesell.

Obtained funding: Diamond.

Administrative, technical, or material support: Diamond, Genoff, Gonzalez, Sharaf, Mikesell, Gany.

Study supervision: Diamond, Sharaf, Gany.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: Dr Diamond was supported by Memorial Sloan Kettering Cancer Center, Department of Psychiatry and Behavioral Sciences, Immigrant Health and Cancer Disparities Service.

Role of the Funder/Sponsor: Memorial Sloan Kettering Cancer Center and the Association of American Medical Colleges had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

US Census Bureau. American community survey, language spoken at home by ability to speak English for the population 5 years and over, 2007-2011, American community survey 5-year estimates: US Census B16001.http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml. Accessed May 31, 2014.
US Department of Health and Human Services. Limited English proficiency (LEP), LEP resources and tools.http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/. Accessed August 29, 2013.
Diamond  LC, Luft  HS, Chung  S, Jacobs  EA.  “Does this doctor speak my language?” improving the characterization of physician non-English language skills. Health Serv Res. 2012;47(1 pt 2):556-569.
PubMed   |  Link to Article
Jacobs  EA, Diamond  LC, Stevak  L.  The importance of teaching clinicians when and how to work with interpreters. Patient Educ Couns. 2010;78(2):149-153.
PubMed   |  Link to Article
Prince  D, Nelson  M.  Teaching Spanish to emergency medicine residents. Acad Emerg Med. 1995;2(1):32-36.
PubMed   |  Link to Article
Diamond  L, Chung  S, Ferguson  W, Gonzalez  J, Jacobs  EA, Gany  F.  Relationship between self-assessed and tested non-English-language proficiency among primary care providers. Med Care. 2014;52(5):435-438.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
2013 Applicants With at Least Self-rated Advanced Proficiency in a Non-English Language in the United States

The data presented in this figure are from the US Census Bureau.1 The following categories, which were among the top 25 languages, were excluded: other Indic languages, African languages, other Asian, other Indo-European, other Pacific, and other Slavic. LEP indicates limited English proficiency.

aIncludes Cantonese, Mandarin, and other dialects.

bRefers to all LEP speakers in the United States; therefore, in 2013, there were 105 applicants with at least advanced proficiency in any non-English language for every 100 000 LEP speakers.

cThe US Census Bureau combines both Spanish and Spanish Creole.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  2013 Residency Applicants by Ethnic Self-identity and Citizenship/Immigration Status

References

US Census Bureau. American community survey, language spoken at home by ability to speak English for the population 5 years and over, 2007-2011, American community survey 5-year estimates: US Census B16001.http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml. Accessed May 31, 2014.
US Department of Health and Human Services. Limited English proficiency (LEP), LEP resources and tools.http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/. Accessed August 29, 2013.
Diamond  LC, Luft  HS, Chung  S, Jacobs  EA.  “Does this doctor speak my language?” improving the characterization of physician non-English language skills. Health Serv Res. 2012;47(1 pt 2):556-569.
PubMed   |  Link to Article
Jacobs  EA, Diamond  LC, Stevak  L.  The importance of teaching clinicians when and how to work with interpreters. Patient Educ Couns. 2010;78(2):149-153.
PubMed   |  Link to Article
Prince  D, Nelson  M.  Teaching Spanish to emergency medicine residents. Acad Emerg Med. 1995;2(1):32-36.
PubMed   |  Link to Article
Diamond  L, Chung  S, Ferguson  W, Gonzalez  J, Jacobs  EA, Gany  F.  Relationship between self-assessed and tested non-English-language proficiency among primary care providers. Med Care. 2014;52(5):435-438.
PubMed   |  Link to Article
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