Student-Led Medical Mandarin Summer Course for Medical Students With Existing Mandarin Fluency

Abstract

Introduction

In regions with significant Mandarin-speaking populations, language discordance in health care poses considerable challenges. Previous studies have shown that patients with language-concordant providers had higher ratings of satisfaction and trust. Despite this, there is a shortage of Mandarin-speaking primary care physicians in California. Thus, it is imperative for medical schools to offer education in medical Mandarin.

Methods

We implemented a medical Mandarin summer course at the University of California, Irvine, School of Medicine. The course targeted medical students with existing Mandarin fluency and used a flipped classroom model, spanning three sessions focusing on medical history, symptomatology, and medical conditions. Sessions consisted of a 2-hour interactive Zoom class starting with an interactive presentation to practice Mandarin medical terminology and cultural competency learned at home. Students were then paired in breakout rooms to practice patient interviewing. Pre- and postcourse evaluations were given to assess language confidence (Likert scale) and competence (graded terminology exam).

Results

Seventeen students participated in the course and had increased ratings in comfort in taking a medical history in Mandarin (p = .001) and cultural competency (p = .05), as well as increased exam scores (p =.01), when comparing pre- and postcourse evaluations.

Discussion

Adding medical language training to existing medical school curricula can cultivate a more linguistically competent health care workforce, ultimately improving patient satisfaction and outcomes. This pilot course demonstrates a feasible approach to addressing linguistic diversity in health care and can be replicated at other institutions to train language-concordant physicians.

Educational Objectives

By the end of this activity, learners will be able to:

• 1.Demonstrate improved confidence in conducting a simple medical interview in Mandarin, including chief complaint, history of present illness, medications, allergies, medical history, family history, and social history.
• 2.Identify and describe Mandarin medical terminology related to symptomatology and simple medical conditions.
• 3.Demonstrate an increase in awareness of culturally relevant knowledge to effectively treat Mandarin-speaking patients.

Introduction

In California, there is a significant concentration of individuals of Asian heritage. According to the US Census, 15.4% of the California population identified as Asian in 2020, with Chinese being the second highest non-English language spoken at home.^1,2 However, when considering how prepared health care workers are to serve this population, California in particular has a shortage of Mandarin-speaking primary care physicians relative to the Chinese population.³ Language discordance has been linked to underutilization of health care services and poorer health outcomes, even when there is an interpreter available.⁴ According to a 2021 AMN Healthcare report, Mandarin is one of the top 10 languages spoken in health care encounters other than English in 47 states, making it increasingly relevant for medical professionals to address the growing Mandarin-speaking population.⁵ Many medical school curricula in the United States lack in-depth training in Mandarin, limiting students’ ability to communicate effectively and understand cultural nuances. One way to address this issue is to train more language-concordant physicians by providing medical language courses during medical training. We implemented a new medical Mandarin summer course at the University of California, Irvine, School of Medicine (UCISOM) to overcome language differences and foster a deeper understanding of cultural aspects of patient care, thereby enhancing the quality of health care delivery to Mandarin-speaking patients.

The primary participants in the medical Mandarin curriculum were medical students with at least a beginner-level understanding of Mandarin. By recruiting students with some existing Mandarin proficiency, the course could focus more on developing medical vocabulary, fluency, and cultural competence, rather than on basic Mandarin grammar and vocabulary. Fluent Mandarin speakers, even those in medical school, often lack exposure to specialized medical jargon and patient interaction skills in Mandarin, making our course particularly beneficial for this demographic.

Limited studies have assessed the impact of a Mandarin medical terminology course on medical students. While much preexisting literature has examined the efficacy of non-English language instruction such as Spanish for medical professionals,^6,7 few examples exist for Mandarin. A 2009 MedEdPORTAL publication described a 2-hour medical Mandarin course taught to practicing physicians and other health care providers.⁸ This course received high ratings of satisfaction from participants for gaining a deeper understanding of Chinese culture, introduction to Pinyin (standardized system for romanizing characters), pronunciation feedback, and medical terminology. However, due to a 2-hour time constraint, the study participants were taught only basic phrases spoken in a clinical setting and an introduction to Pinyin as a means of building a foundation to be later refined. Our course added interactive patient interview practice on top of medical terminology and discussion of Chinese culture. Additionally, course efficacy was evaluated objectively through a pre- and postcourse medical terminology quiz, along with subjective satisfaction and confidence ratings.

We designed the summer medical Mandarin course for incoming first- and second-year medical students (MS 1s and MS 2s) at UCISOM. The purpose of this course was to provide students who had existing Mandarin fluency with the vocabulary to take a full medical history in Mandarin and to discuss culturally sensitive practices in medicine. To the best of our knowledge, this summer-only, 6-hour course is the first of its kind. By sharing our work, we aim to encourage the implementation of similar courses at other institutions.

Methods

Our curriculum included medical interview questions and common medical terminologies in Mandarin based on the UCISOM clinical foundations course. We adapted many of our medical terms from the medical Mandarin curriculum developed by the Chinese Medical Interest Group at the David Geffen School of Medicine at the University of California, Los Angeles.⁹ New terms that we added to our curriculum were chosen and translated by two Mandarin-speaking medical students and further reviewed by two Mandarin-speaking medical professionals.

Our course included 17 MS 1s and MS 2s and four MS 2 facilitators. MS 2s were recruited through an email to the entire MS 2 class, and MS 1s were recruited through a post on the incoming class's Facebook group. Students were required to have at least a self-rated beginner to intermediate Mandarin-speaking level, and students who had no previous exposure to Mandarin were not included in the pilot course. Facilitators were required to have an intermediate to advanced Mandarin-speaking level. Students and instructors chose their proficiency levels using the Common European Framework of Reference for Languages (CEFR).¹⁰ The CEFR included a self-assessment grid (Appendix A) dividing language proficiency into four categories: reception (listening and reading), production (speaking and writing), interaction (speaking and writing), and mediation (translating and interpreting). The CEFR resulted in six possible levels of proficiency: A1, A2, B1, B2, C1, and C2, with C2 being the most proficient. All curriculum materials included accompanying Pinyin to help students sound out the written characters. Thus, students self-evaluated only their listening comprehension and speaking levels, whereas reading levels and writing levels were not evaluated. Students were divided into groups based on their chosen listening and speaking proficiency.

As a summer course, the curriculum was structured to be more efficient than a traditional medical language course during the school year. Instead of weekly didactic lectures, we adopted a flipped classroom model where workbooks (Appendices B–D) and online flashcards (e.g., Anki, Appendix E) were completed before class. Workbooks included medical interview questions and terminology in English, simplified Chinese with Pinyin, and traditional Chinese. Online flashcards contained the same content found in the workbooks but in flashcard form. Each class was conducted for 2 hours biweekly over Zoom. We dedicated the first 30–45 minutes of each class to reviewing workbook materials and online flashcards through interactive PowerPoints (Appendices F–H) that included translation questions and fill-in-the-blank phrases.

At the end of the presentation section, we included a cultural discussion about topics pertinent to treating Mandarin-speaking patients. For example, during class 1, we explored strategies for crafting culturally sensitive dietary suggestions. We recommended avoiding a blanket endorsement of the Mediterranean diet for Mandarin-speaking patients and suggested offering culturally relevant alternatives that would align with each individual's dietary preferences. Other cultural points that were discussed included patient autonomy, interpretation services, and navigating use of herbal and alternative medicines with Mandarin-speaking patients. We spent approximately 10 minutes of each 2-hour session in open discussion about these cultural points.

After this presentation, students were paired with a partner and put into Zoom breakout rooms to practice clinical interviewing. Each group was given two patient scenarios and scripts, allowing each member to take turns practicing. For example, student A followed the script as the patient for patient scenario A (Appendices I–K), then switched roles to practice interviewing the patient, typically without a script, for patient scenario B (Appendices L–N). These patient scenarios used terminology and topics that correlated with the relevant material of the week. Through this format, each student could immediately put into practice the skills they had learned.

The flipped classroom structure enabled the curriculum to consist of 2-hour sessions held biweekly through the summer, for a total of 6 hours of in-class time. We based our curriculum on the patient history checklist given to us during our UCISOM clinical foundations course in the 2022–2023 school year. The first session addressed the outline of the checklist, including how to acquire a chief complaint, history of present illness, medications, allergies, medical history, family history, and social history. The second session expanded on symptomatology, including pain descriptors, basic anatomy, and review of systems questions. The third session covered medical conditions and miscellaneous clinic terms that did not fit clearly within the themes of the previous two sessions.

Students were evaluated with a precourse survey and a postcourse survey (Appendix O), which included confidence and competence measures. Students were asked to rate the following categories on a 5-point Likert scale (1 = not at all confident, 5 = very confident): confidence in communication in Mandarin, confidence in using medical terminology in English and Mandarin, comfort in medical history taking in English and Mandarin, and cultural awareness. For competence measures, students were asked to translate medical terms from English to Mandarin (seven questions), translate medical terms from Mandarin to English (eight questions), and answer fill-in-the-blank questions (three questions). Two Mandarin-speaking medical students created 36 quiz questions, ensuring they covered the medical Mandarin vocabulary list evenly across the three classes. Two native Mandarin speakers rated the difficulty of the questions based on term frequency in nonmedical contexts. We split the questions between the precourse and postcourse quizzes to ensure each had 18 questions with similar difficulty. Finally, two Mandarin-speaking medical professionals reviewed and validated the questions and answers.

The postcourse survey also asked students to indicate which classes they had attended synchronously through Zoom (during scheduled class time) or asynchronously (in which they met with their partners outside of class time to practice interviewing with patient scenarios), as well as classes that they did not attend. Students were asked in the postcourse survey to rate the following class materials on a 5-point Likert scale (1 = not at all helpful, 5 = very helpful): workbooks, patient case scenarios, Anki decks (online flashcards), interactive lecture and PowerPoints, and breakout rooms during class time. General feedback and suggestions were also requested via free response. An anonymous feedback form was made available throughout the course (Appendix P).

Results

Seventeen students enrolled in the pilot medical Mandarin program, including six incoming MS 1s, 10 incoming MS 2s, and one MD-PhD first-year graduate student. The precourse survey had a 100% response rate. The participating students reported having had previous exposure to Mandarin through various sources, including their family (65%), classes through regular schooling (41%), extracurricular classes (24%), study abroad experiences (18%), and self-study (18%). The majority of students self-ranked their listening comprehension levels as A1 (24%), A2 (24%), and B1 (24%), and their spoken interaction levels as B1 (29%), A1 (24%), and B2 (24%; Table 1).

Table 1. Demographics (N = 17).

The postcourse survey had a 100% response rate. Class 1 had a 100% synchronous participation rate. In class 2, 70% of participants attended the session synchronously through Zoom, 6% engaged asynchronously, and 24% did not attend. Class 3 recorded a 53% attendance rate synchronously through Zoom, 6% asynchronous participation, and 41% who did not attend (Table 2).

Table 2. Student Participation and Attendance (N = 17).

In terms of resource utility, most students found breakout rooms during class time (82%), interactive lectures and PowerPoints during class (82%), and patient case scenarios (76%) to be helpful or very helpful. In contrast, workbooks (59%) and Anki decks (online flashcards; 36%) received lower ratings (Table 3).

Table 3. Student Evaluation of Program Resources (N = 17).

Pre- and postcourse survey results were evaluated for significance using the Wilcoxon signed rank test. Both the pre- and postcourse surveys had a 100% response rate. Of note, we observed statistically significant increases in student comfort levels in taking medical histories in Mandarin (precourse M = 1.8, SD = 1.0; postcourse M = 2.9, SD = 0.9; p = .001). Students exhibited a notable rise in awareness regarding cultural differences in Mandarin-speaking populations (precourse M = 3.4, SD = 1.2; postcourse M = 4.1, SD = 0.7; p = .05). There was also a significant improvement in students’ quiz scores from before to after the course (precourse M = 10.4, SD = 4.4; postcourse M = 13.9, SD = 3.7; p = .01; Table 4).

Table 4. Student Ratings and Quiz Scores Before and After Course Self-Assessment (N = 17).

Discussion

The medical Mandarin summer course was developed to bridge linguistic and cultural gaps between future physicians and Mandarin-speaking patients. The course aimed to provide beginning to intermediate Mandarin-speaking medical students with the vocabulary to conduct a full medical history in Mandarin, while also emphasizing cultural competence. Our decision to implement this course during the summer benefitted both the facilitators, who had more time to prepare for each session, and the students, who could dedicate more time to studying the material. To accommodate varied student availability during the summer, we adopted a flipped classroom style, allowing students to learn asynchronously through workbooks and online flashcards. Both these resources included questions and medical terminology in English, simplified Chinese, traditional Chinese, and Pinyin to accommodate students who might be more familiar with one form of Chinese over another. The biweekly 2-hour Zoom sessions enabled students to reinforce their learning through PowerPoint assessments and by simulating real Mandarin medical interviews with their peers. This type of medical Mandarin summer course was the first of its kind, and the results of our pilot course illustrate the efficacy of its structure.

Our highest-rated curriculum components were the Zoom breakout rooms (82% positive ratings) and the patient case scenario sheets (76% positive ratings). This indicates that interactive peer-to-peer language instruction emerged as the most well-received component of this course. In contrast, the workbooks (59% positive ratings, 24% did not use) and online flashcards (36% positive ratings, 47% did not use) saw lower utilization and received lower ratings. These findings suggest that conventional language-learning methods, such as vocabulary workbooks and flashcards, may not be as effective as interactive, peer-to-peer approaches when applying language skills in a medical context.

The significant improvement in the comprehensive quiz scores highlights the efficacy of the 6-hour summer course in improving proficiency in medical Mandarin terminology. Additionally, there was a significant increase in awareness of cultural differences in Mandarin-speaking patient populations, despite dedicating only 30 minutes of total class time to this topic. The enhanced cultural competency scores underscore the importance of even brief discussions on cultural matters.

The course's emphasis on teaching medical Mandarin terminology was reflected in the notable increase in comfort with taking a medical history in Mandarin, without a similar improvement in English history-taking skills. Additionally, there was no significant improvement in overall Mandarin communication or confidence in using medical Mandarin terminology. As the course was not designed to be a comprehensive language program, improvements in overall communication were not anticipated. The lack of improvement in confidence in using terminology may be linked to the lower usage of workbooks and online flashcards, which were intended to help students practice terminology. Given that most students engaged with the patient case scenarios and breakout rooms—resources designed for practicing medical interviewing—an improvement in history taking was expected.

This study had several limitations. It was primarily conducted by students over the summer without faculty support, and the small sample size of 17 students restricts the generalizability of our findings. Additionally, the inclusion criteria required participants to have existing Mandarin fluency, making the results most applicable to those with exposure to the language. Relying on self-rated proficiency levels might have introduced subjectivity, potentially leading to overestimation or underestimation of language abilities. Additionally, while convenient, a 6-hour course certainly does not ensure sustained knowledge or communication skills. The short duration of the summer pilot course also limited the incorporation of specific language nuances, such as regional dialects, and may not have fully captured the challenges that a medical student or physician might encounter when interacting with Mandarin-speaking patients. Future iterations of the course could introduce the concept of dialect variations in Mandarin.

Although all learning materials included Pinyin and students were able to practice interviewing with peers, we did not directly assess verbal ability and improvement through verbal performance evaluations. Furthermore, our teaching focused mainly on questions to be posed during medical interviews and did not include guidance on follow-up techniques. For future iterations, we recommend adding verbal performance evaluations and incorporating more one-on-one practice sessions to practice follow-up skills.

We observed a significant drop in student participation from the first to the third class. As summer advanced, numerous students faced challenges attending synchronous sessions or participating asynchronously. Notably, 41% of students did not attend the third class. While some students had already indicated their unavailability for classes 2 and 3, there were also instances of no-shows in the last two sessions. Despite this decline, survey results indicate that students still improved their confidence in Mandarin history taking. This improvement underscores the substantial impact of class 1, which concentrated on the essential questions for taking a medical history during annual physicals. The subsequent sessions broadened the scope to include pain descriptors and disease names. Shorter class iterations might achieve similar results, along with higher retention rates.

The evaluation of the course consisted of administering a pre- and postcourse survey to self-evaluate both confidence and technical knowledge of terminology. While precourse collection was roughly at equivalent time points (directly before the first session), postcourse survey collection points did vary, with the last response recorded at 5 weeks after the last class. This may have impacted the data, especially those regarding knowledge of terminology.

Future plans involve extending the pilot program into a full-length elective course offered during the academic year, which would provide elective credit. Future iterations of the course might consider using validated instruments to assess pre- and postcourse confidence and proficiency. This could include developing assessment tools for evaluating medical Mandarin oral language proficiency, akin to established instruments like the Physician Oral Language Observation Matrix designed for the Spanish language or the American Council on the Teaching of Foreign Languages oral proficiency interview.¹¹ Due to the virtual nature of this summer course, Mandarin-speaking students from different medical schools could attend simultaneously, which would open this opportunity to students from schools that lack medical Mandarin courses. Future versions could include relevant clinical experiences by pairing students with Mandarin-speaking preceptors in a clinical setting. Additionally, long-term surveys could be conducted to evaluate the course's impact on clinical work, considering the students are in the didactic phase of their medical training and have not yet started clinical rotations. Lastly, integrating medical language and cultural competency training into existing medical school courses can help cultivate a more linguistically and culturally competent health care workforce. This could include having Mandarin-speaking standardized patients for students to further develop Mandarin interview skills. Given the increased patient satisfaction and trust associated with language-concordant physician-patient interactions,¹² prioritizing language training in health professional education can help ensure more effective and empathetic health care services.

This pilot low-commitment medical Mandarin summer course served as an introduction to taking a full medical history in Mandarin for students with prior exposure to Mandarin. Participants showed significant improvement in their confidence with Mandarin medical history taking. The curriculum's short-term and flipped classroom structure makes it an easily implementable course at other institutions to pave the path for more language-concordant physicians.