Examining Language and Immigration Barriers to Reduce Inequalities in Maternal Healthcare: A Conversation with Dr. Rose Molina
Interview by Ro Dudevoir
HUHPR Associate Editor Ro Dudevoir interviewed Dr. Rose Molina, a board-certified Obstetrician-Gynecologist at The Dimock Center and Beth Israel Deaconess Medical Center. Dr. Molina holds a Master of Public Health in Clinical Effectiveness from the Harvard T.H. Chan School of Public Health, and is an Assistant Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School, where she is also the Faculty Director of the Medical Language Program and Health Equity Societal Theme. Additionally, Dr. Molina is a member of Ariadne Labs where she works to improve quality and equity in pregnancy care worldwide. As an AHRQ Learning Health Systems K12 scholar, she leads research on language barriers in pregnancy care and improving patient-clinician trust. She is dedicated to addressing immigration barriers in healthcare and performs asylum evaluations for survivors of sexual assault and gender based violence. Dr. Molina has a passion for examining the intersection of language and immigration as barriers for achieving equitable pregnancy and reproductive healthcare and designing solutions to these challenges. This interview has been minimally edited for brevity and clarity.
Ro Dudevoir (RD): I appreciate you taking the time out of your day to meet with me. Can you begin by introducing yourself and describing your background in Obstetrics and Gynecology?
Rose Molina (RM): My name is Rose Molina and I have been an OB-GYN in practice since 2015. I went to Harvard Medical School (HMS) and then completed an Obstetrics and Gynecology residency, graduating in 2015. Since then, I’ve had a clinical practice at The Dimock Center, which is a federally qualified community health center in Roxbury, Massachusetts. I also continue to do inpatient Obstetrics at Beth Israel Deaconess Medical Center in Boston, Massachusetts.
RD: In addition to your clinical work, you study language barriers and immigration, particularly as they are relevant to the OB-GYN field. Can you tell us about your motivation for studying these issues and how it applies to your career as an OB-GYN?
RM: The motivation actually stems from my childhood and where I grew up. I grew up in San Diego, the largest city on the Mexico-United States border. I grew up in a multicultural, interracial family in Southern California. My mother was born in Hong Kong and insisted that my brothers and I learn Mandarin so that we could communicate with our extended family. My father is a descendant of Irish and Czech immigrants, and he was born and raised in California, where over half of the population speaks Spanish. My father learned Spanish as a young adult and insisted my brothers and I learned Spanish because of where we lived growing up. With that background, from a very young age, I became interested in languages as a means for building connections with people from across different cultural and ethnic backgrounds.
To this day, I am fluent in Spanish and because of my work at The Dimock Center in Roxbury, I see a large number of Spanish-speaking patients. In fact, nearly 90-100% of the patients that I see in the clinic are Spanish-speaking. Many of them share with me their stories and journeys around immigration and how that intersects with their health and healthcare access. These are the stories that motivate my research in which I study this intersection of language and immigration as barriers for achieving equitable pregnancy and reproductive healthcare.
RD: How do you observe these language barriers in your everyday work and what are the effects of these barriers?
RM: I observe all of these barriers through stories that my patients share with me. Many challenges come from inequitable language access. Despite having federal and regulatory requirements for meaningful language access in medical settings, this is not a reality for every patient who needs language access every time they need it in health care. In fact, we are very far from meeting the ‘gold standard’ language access we should be fulfilling for patients. Many of my patients have reported miscommunications with healthcare teams because of a language barrier where either they tried to communicate in sub-optimal English or the healthcare team tried to communicate with them in sub-optimal Spanish. Other times, an interpreter was not called at all or an interpreter was called but the meaning and actual interpretation was not perfectly understood by either or both parties. I hear a lot about miscommunication.
One example is notifying patients about appointments. If the person who called them does not leave a message in that language or with an interpreter, then, of course, the patient will not understand the message and will miss an appointment because the information was not communicated in a way that they could understand.
I also hear a lot about the stigma, discrimination, and bias that people experience simply because they speak languages that are not English. The fact is that the United States has been built intentionally around English. Very few aspects of our society are actually accessible in other languages besides English. As I previously mentioned, I grew up in California, so I think a lot about the names of streets and the signage in public places such as airports. When you look at language access, you will see that despite being incredibly linguistically diverse, the United States is explicitly designed around English with very little access for other languages in everyday life.
Another barrier I observe relates to the intersection between immigration and language. For individuals who may either be undocumented or have uncertain legal status, there is a lot of fear about accessing services and disclosing that information. Thus, they may be hesitant to reach out and ask for referrals or share other healthcare needs.
RD: I see you are the Faculty Director of both the Health Equity and Anti-Racism Theme and the Medical Language Program at Harvard Medical School and a core faculty member at Ariadne Labs, among various other organizational leadership positions you hold for several organizations. Could you tell us more about these programs and the role you play? What are the impacts of your work?
RM: Sure, I’ll pick the first two at Harvard Medical School. Those two roles are centered around medical education specifically. The first role I took on was becoming the first director of the Medical Language Program at HMS. The Medical Language Program was formally launched in 2018; however, medical language training at HMS dates back to the 1970s. In its current form, the Medical Language Program includes a suite of medical language electives that students can opt into taking. We offer longitudinal semester courses in intermediate and advanced Spanish, intermediate Portuguese, intermediate Mandarin, and most recently we have added intermediate French and Arabic. We have also added pilot courses based on student demand. For example, last year, we held our first American Sign Language elective. We also offer an intensive medical Spanish course, which is geared more towards the beginner to intermediate level. Additionally, we offer opportunities for students to engage in exchange electives or rotations abroad where they can practice their language skills through immersion.
The Medical Language Program is comprised of all of these different electives and opportunities to build a multilingual physician workforce. It is designed to help students who come into medical school with pre-existing language skills to improve upon those skills to the point that they could hopefully engage in direct clinical care with patients without the need for an interpreter, which is usually the motivating factor for students to take these classes. These students want to be able to provide language concordant care and may need some additional practice or training with certain medical terminology before approaching patients with specific language skills.
With regard to the Health Equity and Anti-Racism Theme, this is a role that I took on in the Fall of 2021. This is a longitudinal curriculum for integrating health equity and anti-racism education throughout the four-year curriculum for HMS students. As part of that, in collaboration with students and faculty, I have developed four competencies around health equity and anti-racism as well as associated learning objectives. We are currently working on mapping our curriculum and developing new content for the curriculum in these topic areas.
RD: You have published several papers, many of them regarding language barriers in healthcare and specifically pregnancy care. Can you speak on your research? What challenges do you face when implementing this research into solutions to guide healthcare policy?
RM: My research is broadly about advancing equitable pregnancy care with a particular focus on those who face language and immigration barriers. I’m currently on a K12 award which is a career development award through the Agency for Healthcare Research and Quality. As part of this award, my focus is on developing a patient reported outcome measure for trust in pregnancy care clinicians among Spanish-speaking patients, a population that is otherwise often not included in patient-reported outcomes research.
The second part of my current project is developing a tool to enhance communication and trust when language differences exist between patients and clinicians. One of the challenges I face is developing and learning the methods to do bilingual research in Spanish. Doing any sort of research in another language comes with a whole host of additional challenges, such as ensuring I have a bilingual research team, ensuring we have the budget for the appropriate translation of materials, and adding in time for building relationships with communities that are often not engaged in the healthcare or research setting due to a language barrier. All of these things have added complexity to performing this type of research.
One of the areas that I care deeply about is immigration status as a structural determinant of health. It is an underexplored area because of the security risks of collecting data around immigration status. Clearly, we do not want to be putting anybody’s livelihood at risk by disclosing that information if that information were to ever get in the wrong hands. Therefore, this means that conducting research among this population is particularly difficult. There remain a lot of open questions to answer surrounding the health outcomes and experiences specific to undocumented individuals. This is an area that I am beginning to work on even more but certainly comes with its own set of challenges.
RD: What do you believe the next steps are in eliminating language barriers and disparities in maternal health? How can doctors best support their patients when these barriers are present?
RM: There are many things that we need to do to overcome language barriers and improve more equitable care, specifically in maternal health. I recently wrote a commentary in collaboration with several OB-GYN residents and faculty specific to our field regarding the drivers and potential solutions for language justice in obstetrics and gynecology. The solutions span everything from individual action that clinicians can take to health systems transformation to changes at the broader societal level. At the societal level, as I mentioned earlier, our public signage is significantly lacking. I live in a city where we do a fairly good job in terms of public multilingual signage in certain places, but this is not embraced in our society universally in terms of providing multilingual access for everyday life. I believe public schools tend to do it quite well. I've seen some specific places such as libraries that may offer more linguistic access. However, the vast majority of spaces in our country are not multilingual, and thus, there is a lot to be done at the broader societal level.
At a more specific clinician level, I believe one of the things that is becoming more discussed is the use of qualified language assessments. In the past, and currently in many places, the default is that a clinician would self-report if they spoke another language and there was no proficiency assessment to actually verify whether that is true or not. The challenge with this is that there is a large literature showing that there are safety concerns, adverse events, and miscommunications that happen because some clinicians will overestimate their language skills which leads to incomplete communication and errors. Only recently have some healthcare systems begun to actually measure clinician language proficiency to certify that an individual has the necessary language skills to be using them in direct patient care. The clinician has to sign up and actually take the assessment, but of course, there’s a whole system behind the assessment that has to be in place in terms of figuring out the cost as well as how to acknowledge that a clinician has passed a certain assessment. In some systems, they have compensated clinicians differentially based on their language skills and treated it as a skill that is deserving of differential compensation.
Another area that is also quite promising is linguistic access through Artificial Intelligence (AI) powered technology. There is a lot of opportunity on the horizon around harnessing technology to more rapidly translate materials. The tricky thing is at this point, the available technology alone is not 100% accurate and still requires a human in the loop to verify the accuracy of interpretation, meaning, and cultural context. Perhaps in the near future the technology will improve to the point where translation and interpretation will be made much more rapid, accurate, and accessible. This is all very exciting.
The final topic we discussed in the commentary was thinking fundamentally differently about what language barriers mean in clinical care. It is simply inappropriate to imagine that the same quality visit would happen in English as it would in another language when an interpreter is present. A visit often takes double the time when an interpreter is present. This needs to be recognized in the reimbursement process, as well as when allocating clinical slots when an interpreter is needed. It needs to be acknowledged that language interpretation truly does take more time and adds more complexity to the visit. At this point, I believe that very few systems actually incorporate this complexity when they create their schedules and make decisions about clinical operations.
RD: What has been the most rewarding experience or aspect of your work thus far? What do you hope to focus on moving forward?
RM: One of the things that I do that gives me the most meaning and professional joy is performing asylum evaluations. Since I completed the training for 2016, I have performed over 20 evaluations, most commonly for survivors of sexual and gender-based violence. It is these moments that carry me through a lot of the harder parts of my job, and I believe it is because it gives me an opportunity to really listen to people and their stories of struggle and resilience. It also gives me a space to use my skills for a very tangible purpose that is life changing for an individual and their family. This is something that I find very rewarding. I do it on my own time, and it is not something that I receive any funding for. However, it is something that I find is the most meaningful.
In terms of where I would want to focus moving forward, as I mentioned earlier, I care deeply about immigration status and it has been a difficult topic to delve deeply into with regard to research because of some of the security challenges involved. This is something I hope to invest more time into in the years to come.
RD: This is all very exciting. Once again, thank you so much for meeting with me and sharing your incredible work with us!
Dr. Rose Molina is a board-certified Obstetrician-Gynecologist at The Dimock Center and Beth Israel Deaconess Medical Center. Dr. Molina holds a Master of Public Health in Clinical Effectiveness from the Harvard T.H. Chan School of Public Health, and is an Assistant Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School, where she is also the Faculty Director of the Medical Language Program and Health Equity Societal Theme. Additionally, Dr. Molina is a member of Ariadne Labs where she works to improve quality and equity in pregnancy care worldwide. As an AHRQ Learning Health Systems K12 scholar, she leads research on language barriers in pregnancy care and improving patient-clinician trust.