Decolonizing medical education: a systematic review of educational language barriers in countries using foreign languages for instruction | BMC Medical Education

This review highlights the profound challenges posed by language barriers in foreign-language-based medical education, particularly in countries where instruction is delivered in a non-native language. These barriers significantly affect academic performance and patient communication, emphasizing the need for reforms that balance the benefits of internationalization with the practical advantages of native-language instruction. Such reforms could improve educational outcomes and healthcare delivery while maintaining global competitiveness.

The argument for internationalization vs. native language dependence

The debate between using English as the medium of instruction and relying on native languages is central to the future of medical education [3, 62]. On one hand, English is the dominant language of global medical research, scientific communication, and international collaboration. Adopting English as the medium of instruction allows students and professionals in non-English-speaking countries to access a vast repository of medical knowledge, participate in global conferences, and collaborate with international peers. For example, many students of the included studies, while faced challenges in English-medium instruction, acknowledged its importance for global scientific engagement.

On the other hand, the reliance on English in countries where it is not the native language creates significant barriers for students. Studies from the Arab world demonstrate that students often struggle with comprehension, retention, and application of medical knowledge when taught in English. Linguistic differences between L1 (Arabic) and L2 (English) further exacerbate these challenges. For instance, Kakar and Sarwari (2022) found that L1 (Farsi Dari) can both scaffold and interfere with L2 (English) communication [63]. While L1 proficiency helps generate ideas, improve self-esteem, and reduce anxiety, it also creates interference in pronunciation, grammar, and vocabulary. These findings align with the challenges faced by medical students in the Arab world, where Arabic (L1) often interferes with English (L2) medical terminology and communication. This disconnect not only hampers academic performance but also affects students’ ability to communicate effectively with patients in their native language, as seen in Hashim and Mirza studies [11, 29]. The preference for native language instruction is evident in studies like Jabali 2022, where 50% of Palestinian medical students favoured Arabic over English, citing better comprehension and patient communication [33].

A balanced approach that enhances English proficiency while incorporating native language instruction may offer the best of both worlds [3]. For instance, bilingual education programs, such as those combining Arabic and English in clinical training, have shown promise in bridging the gap between global standards and local needs [64, 65]. By teaching core medical subjects in the native language and providing supplemental English classes, students can achieve better comprehension of complex concepts while maintaining the ability to engage with international medical literature and practices.

Academic and educational barriers

The studies reviewed highlight that foreign-language instruction, particularly in English, presents significant challenges to students’ academic performance. Overwhelming evidence from countries like Saudi Arabia and the United Arab Emirates shows that students often struggle to comprehend English-language textbooks and assessments, leading to suboptimal learning outcomes, increased stress, and higher dropout rates [10, 19]. These findings resonate with the need to reconsider language use in medical curricula, especially in non-English-speaking countries. While English proficiency is important for global scientific engagement, it should not come at the cost of students’ comprehension and success in their primary education [3].

Integrating native-language instruction into medical education would likely reduce these academic barriers. As demonstrated in the results, when students struggle with foreign-language comprehension, their academic performance suffers, resulting in increased stress and reduced retention of critical knowledge. A bilingual approach, where core subjects like anatomy, physiology, and pathology are taught in students’ native languages, can help ease their linguistic challenges while fostering better understanding and engagement with complex medical concepts [64, 65]. The incorporation of native-language training could thus lead to improved academic outcomes, ensuring that students are better prepared for clinical practice.

Patient communication and cultural competence

The second major theme identified in the review is the impact of language barriers on students’ ability to communicate effectively with patients. Medical students trained in foreign languages often report difficulties in conveying empathy, gathering medical histories, and addressing patients’ concerns in their native languages. Students trained primarily in English, for example, may have a good grasp of medical terminology but find it challenging to apply this knowledge in their native language, which is crucial for building rapport and providing culturally sensitive care.

Many included studies highlighted that students were more comfortable and confident in-patient interactions when using their native language, illustrating how language can influence the quality of healthcare interactions. Medical education systems that rely solely on a foreign language for training inadvertently create a gap in effective communication between students and patients, leading to poorer patient outcomes [11]. Furthermore, this issue extends beyond language skills; it also involves cultural competence. In many regions, including the Middle East, healthcare delivery is deeply influenced by cultural norms that shape the way patients express concerns and interact with healthcare providers. The inability of students to effectively communicate in their native language can hinder their ability to engage with patients in culturally appropriate ways, ultimately impacting the quality of care [9]. To address these barriers, incorporating native language instruction in communication skills training is essential.

Pedagogical implications and feasible solutions

The findings of this review have significant implications for medical education, particularly in countries where foreign languages are used as the medium of instruction. Based on the evidence, we propose actionable strategies and feasible solutions to address language barriers and improve educational outcomes. Adopting bilingual education, where students learn both in a foreign language and their native language, presents a feasible starting point in the transition towards fully native language-based medical education. A fully native language-based medical education does not imply abandoning English, which remains the leading language of global medical research and communication. Instead, it emphasizes the importance of learning English alongside the native language to ensure students are equipped for both local and international contexts. The studies reviewed suggest that bilingual programs, such as those combining Arabic and English in clinical training, offer a practical solution for addressing language barriers. These programs help students bridge the gap between their native language and the foreign language of instruction [64].

AI tools, particularly advanced translation technologies and large language models, can significantly support this transition to native-language education. AI-driven translation systems could enable students to translate any medical content—whether textbooks, research articles, case studies, or clinical guidelines—into their native language, thereby overcoming the limitations of foreign-language instruction [66]. This would allow students to access all learning materials in a language they are comfortable with, improving comprehension and facilitating deeper learning.

Complexities in multilingual nations and the role of english-medium schools

The situation of language barriers in medical education becomes more complex in multilingual nations, where multiple languages coexist, and each region or state may have its own dominant language. For example, in countries like India, where there are 22 officially recognized languages and hundreds of dialects, the choice of language for medical education is not straightforward [67]. Patients in such settings often communicate in their regional languages, which may differ from the language of instruction in medical schools. This creates additional challenges for medical students, who must navigate multiple languages to effectively communicate with patients and deliver culturally sensitive care [22, 54].

Moreover, the prevalence of English-medium schools in many British Commonwealth nations, including India, adds another layer of complexity. In these schools, all subjects are taught in English, and students often become more proficient in English than in their native or regional languages. While this familiarity with English can facilitate the transition to English-based medical education, it may also lead to a disconnect between students and patients who primarily communicate in local languages. For instance, Amulya et al. found that 88.5% of medical students in India struggled to communicate comfortably in the local language during bedside teaching, despite being educated in English [22]. This highlights the need for medical curricula to address both the linguistic diversity of patients and the varying levels of language proficiency among students.

In such contexts, a one-size-fits-all approach to language in medical education is unlikely to be effective. Instead, tailored solutions that consider regional linguistic diversity and the prevalence of English-medium education are needed. For example, medical schools in multilingual nations could adopt a flexible approach, offering instruction in both English and the dominant regional language(s). This would allow students to develop proficiency in the languages most relevant to their clinical practice while maintaining the ability to engage with global medical knowledge. Additionally, communication skills training could be designed to address the specific linguistic needs of different patient populations, ensuring that students are well-prepared to provide effective and empathetic care in diverse settings.

Policy implications

Policymakers have an important role in shaping educational reforms that address these language barriers. The successful incorporation of native-language medical education, as seen in several global initiatives, shows that it is possible to align with international medical standards while respecting local linguistic and cultural contexts [3]. Countries could adopt a gradual shift towards native-language curricula for foundational medical subjects, combined with ongoing English language support to maintain international competitiveness. A policy shift in this direction would not only improve students’ educational outcomes but also ensure that healthcare professionals are better equipped to deliver culturally sensitive care.

Strengths and limitations of the study

This systematic review has several strengths, including its comprehensive search strategy across multiple databases (PubMed, Scopus, and Web of Science) and adherence to PRISMA guidelines, which ensured a rigorous and transparent review process. The inclusion of 49 studies involving over 14,500 students from diverse regions, particularly the Arab world, provides a robust evidence base for understanding the impact of language barriers in medical education. Theoretically, this study contributes to cognitive load theory and sociocultural learning frameworks by demonstrating how foreign-language instruction increases extraneous cognitive load and hinders culturally congruent patient care. Additionally, this is the first systematic review to comprehensively examine language barriers in medical education across countries that rely on foreign languages for instruction.

However, this review also has limitations. First, the majority of included studies were conducted in the Arab world, which may limit the generalizability of findings to other regions. Second, the heterogeneity in study designs (qualitative, quantitative, and mixed methods) and outcomes made it challenging to perform a meta-analysis, necessitating a narrative synthesis approach. The review focused on language barriers in medical education but did not explore the broader socio-political and historical factors that contribute to the reliance on foreign languages in many countries [5]. Despite these limitations, this review provides valuable insights into the challenges posed by language barriers in medical education and offers practical recommendations for addressing these issues. Future research should explore the long-term impact of bilingual education programs and the role of technology in bridging language gaps in medical education.