Patient–physician communication is a critical element in health care provision, and the increasing number of Spanish-speaking patients in the United States1 presents a growing challenge for health systems tasked with providing equitable care. According to the 2015 American Community Survey, there are 40 million Spanish-speaking Hispanic/Latino * U.S. residents, representing a rise of 131.2% since the prior survey in 1990; of these, 43% (17.2 million) are monolingual Spanish speakers.1 The Latino population is not only underserved but also underrepresented in the health care workforce in general and in the physician workforce specifically.2,3 As a result, medical Spanish education is in growing demand from U.S. medical students, providers, and health systems. Many medical schools have taken on the task of providing medical Spanish education to their students but have identified significant barriers in designing, implementing, evaluating, and sustaining quality programs.4
Some of the barriers to medical Spanish courses include the time needed to develop new courses, limited space within the curriculum to insert courses, limited availability of faculty with the expertise to teach such a course, and limited funds to compensate these faculty for their time.4 In addition, important elements of medical Spanish courses have been proposed, but their implementation has not been evaluated.5 The most complete survey available of existing medical Spanish courses was completed in 20124 and showed that a majority of MD-granting medical schools (55%) had a medical Spanish course. However, no formal follow-up has been done to date, and no current mechanism exists for programs to communicate with each other to share resources or data on medical Spanish educational techniques or evaluation processes. Further, existing medical education curriculum inventory processes do not capture data on elective medical Spanish courses.6
Several medical Spanish programs have been reported in the literature, but few meet best practice criteria, including a reliable method of individual student and overall program assessment and evaluation.7 Lack of assessment results in medical students and physicians, without confirmation of proficiency, using variable language skills with patients out of perceived necessity, which can jeopardize health care communication with Latino patients and pose significant quality and safety risks to an already vulnerable population.8,9 The current approach to medical Spanish education has relied on each medical school developing its own educational materials, clinical cases, scripts, and scoring rubrics for complex standardized patient (SP) encounters and other curricular components, missing an opportunity for peer review and interdisciplinary and interinstitutional collaboration. Confounding the problem, language training requires longitudinal efforts across the full medical education curriculum and instructors with specialized skills.10 Prior work has proposed a collaborative effort and a multidisciplinary approach to address linguistic issues, including medical Spanish education, in health care.11
Relatedly, medical Spanish educational efforts should be viewed in the context of the U.S. health system’s commitment to provide linguistically appropriate care to all patients. The advancement of health-related diversity, inclusion, and equity is a recognized priority area of U.S. governmental and research-focused institutions, such as the National Institutes of Health, the U.S. Department of Health and Human Services’ Office of Minority Health, and the Patient-Centered Outcomes Research Institute. Federal guidelines mandate nondiscrimination in health care based on language12; however, there are few government-funded programs that directly promote increasing the number of bilingual physicians who can provide language-concordant care. Similarly, academic institutions—such as the Association of American Medical Colleges (AAMC), a national organization that has standardized the curriculum development process for U.S. medical schools—prioritize the advancement of diversity, inclusion, and equity in medical education but do not currently have a standardized curriculum to address medical language proficiencies in non-English languages. The AAMC’s existing curriculum development process presents an opportunity for medical Spanish education, which could follow a similar path to national standardization.
In this context, leaders from the National Hispanic Health Foundation (NHHF) and University of Illinois College of Medicine (UI-COM) convened a multidisciplinary expert panel called the Medical Spanish Summit in March 2018 to address the following objectives: to define national standards for the teaching and application of medical Spanish skills in physician–patient communication, to establish curricular and competency guidelines for medical Spanish courses in medical schools, to propose best practices for medical Spanish skill assessment and certification, and to identify next steps needed for the implementation of the proposed national standards. For the purposes of the summit, the expert panelists agreed on a definition of medical Spanish as “the use of Spanish in the practice of medicine for communication with patients.” The panelists defined the scope of the summit as being to advise on medical Spanish education for U.S. medical students to make actionable recommendations, which could later be adapted and applied as a model for other health professions, multiple stages of physician training and practice, and other languages.
Description of the Summit
The Medical Spanish Summit was convened in Fort Washington, Maryland. A national representation of experts who were identified as key stakeholders in medical Spanish education and language concordance were invited to the summit. Invitations were sent by the summit directors, leaders from UI-COM (P.O.) and NHHF (E.R.), to individuals who had participated in the Debate Forum on Medical Spanish at Harvard University in 2017,13 had previously published on the topic of medical Spanish education, or had been involved in organizations engaged in linguistic components of health services for Latino patients. The summit directors were attentive to including representation of experts from all regions of the United States where Latino patient nationality and linguistic variants may influence medical Spanish needs. Twenty-seven experts attended the Medical Spanish Summit, and an additional 8 experts were unable to attend but participated in post hoc discussions. Participants included physicians, medical educators, academic deans, language researchers, residency leadership, members of private industry, government employees, medical interpreters, and nonprofit organization leadership. A full list of expert panelists is available in Supplemental Digital Appendix 1 (at https://links.lww.com/ACADMED/A724).
Speakers from the expert panel gave presentations on preidentified topics, reviewed existing literature, and discussed current practice pertaining to medical Spanish education. All attendees were then divided into breakout working groups corresponding to 4 components of medical Spanish standardization: curriculum and resources, competencies, provider assessment and certification, and program evaluation. The summit directors had previously identified specific objectives, based on gaps in the literature pertaining to each component of medical Spanish standardization, for each working group to address (Figure 1). The curriculum and resources working group was tasked with determining whether there is a need for a medical Spanish network and, if so, to propose a method of implementation, identifying the recommended resources for medical Spanish education and generating a consensus course syllabus to facilitate curricular implementation. The competencies working group was asked to propose a list of target medical Spanish learner competencies, including recognition of limitations; to propose the recommended qualifications for educators; and to recommend the prerequisite proficiency level for students before enrolling in medical Spanish courses. The provider assessment and certification working group objectives were to recommend assessment processes for medical Spanish learners at course completion and to determine whether a certification exam is needed and, if so, to propose methods of development. Finally, the program evaluation working group was asked to identify next steps in research and for implementation of the summit recommendations and to identify potential collaborators and partnerships.
A leader was preidentified for each of the working groups by the summit directors and was responsible for directing the group’s 2-hour discussion and consolidating their recommendations pertaining to the proposed objectives. A final 2-hour plenary session with all attendees reviewed the key findings and recommendations of each group and allowed for additional contributions to the working group consensus from the summit participants in other working groups. Using notes taken during the event, a draft document was generated and shared with all attendees and post hoc participants for their review and feedback. The recommendations presented in this Perspective are outcomes on which each member of the expert panel agreed after discussion. Areas in which a consensus could not be reached were determined to need additional research to evaluate best practice guidelines.
Final Consensus Recommendations
The final consensus recommendations of the Medical Spanish Summit are summarized in List 1 and discussed in more detail below.
Summary of the Final Consensus Recommendations of the Medical Spanish Summit, Fort Washington, Maryland, March 2018
The medical Spanish expert panel:
- Recommends the creation of a U.S. Medical Spanish Taskforce to define educational standards, provide academic peer review, implement a pilot program, and create partnerships with national and international organizations.
- Recommends integration of medical Spanish educational initiatives with government-funded research and training efforts to advance physician linguistic diversification and skills building as a strategy to improve Latino health.
- Provides a consensus list of core medical Spanish learner competencies to standardize the learning objectives and student performance expectations, targeting learners with intermediate Spanish proficiency.
- Provides a consensus core curriculum as a recommended structure for medical Spanish courses in U.S. medical schools.
- Recommends assessment of medical Spanish learner skills through standardized patient encounters that incorporate interactive communication and interpersonal skills and proposes development of a national certification exam.
- Recommends development of standardized evaluation and data collection processes for medical Spanish programs.
Consensus recommendation 1: The panel recommends the creation of a U.S. Medical Spanish Taskforce to define educational standards, provide academic peer review, implement a pilot program, and create partnerships with national and international organizations
Medical Spanish educational development to date has involved the unintentional duplication of work and a lack of uniform guidelines for teaching or assessing medical Spanish skills. In addition, concerns about unintended consequences of medical Spanish programs leading to inappropriate use of limited Spanish skills in patient care or an inability to recognize self-limitations in Spanish abilities are valid in the high-stakes health care environment.14 A Medical Spanish Taskforce should be created to define and evaluate standards for the teaching and application of medical Spanish in physician–patient communication.
Although the United States is 1 of the top 2 countries in the world in terms of having the greatest number of Spanish speakers,15 additional research is needed to better define medical Spanish language usage in the United States, including linguistic variations and colloquialisms16,17 as well as the extent to which health-related language is understood by Spanish-speaking patients of varied literacy and socioeconomic backgrounds. Through the Real Academia Nacional de Medicina de España and the Asociación Latinoamericana de Academias Nacionales de Medicina, the academies of multiple Spanish-speaking countries are collaborating in the creation of a free online medical Spanish resource known as the Diccionario Panhispánico de Términos Médicos (DPTM)18 to define and centralize medical terminology and usage among patients, communities, and providers in medical settings. Future medical Spanish efforts should evaluate the DPTM’s potential use and applicability in U.S. medical Spanish educational and patient care settings, which may differ from the use and applicability in other countries with large Spanish-speaking populations. A Medical Spanish Taskforce could serve to represent the linguistic repertoires of U.S. Spanish speakers in the development of educational resources, such as the DPTM, to foster interdisciplinary international collaborations and to critically evaluate progress.
Consensus recommendation 1 was drafted by the curriculum and resources working group and confirmed by consensus.
Consensus recommendation 2: The panel recommends integration of medical Spanish educational initiatives with government-funded research and training efforts to advance physician linguistic diversification and skills building as a strategy to improve Latino health
It has been established that the lack of data regarding patient language preference hinders the health system’s ability to address resulting health disparities,19 though this has been improved by recent efforts (e.g., federal mandates for the collection of race, ethnicity, ancestry, and language preference—or R/E/A/L—data).20 However, a persistent lack of documentation of physician language proficiency limits the capacity to conduct patient-centered research of language concordance.11 Further, most research and implementation efforts to date have focused on bridging language barriers almost exclusively through medical interpretation, which is necessary but not superior to high-quality language-concordant care.21
For example, the national Culturally and Linguistically Appropriate Services (CLAS) standards22 do not specifically address bilingual provider language usage, training, or certification recommendations or requirements and have historically had low rates of hospital compliance.23 In the implementation of the Affordable Care Act, Section 1557, the Office of Civil Rights (OCR) has defined the term language assistance as including not only qualified interpreters but also qualified bilingual providers.24 This definition implies that those who are in need of assistance are solely the non-English-speaking patients and not the non-Spanish-speaking staff. Further, the OCR does not clarify how complex bilingual provider skills ought to be tested, demonstrated, or verified.
The expert panelists propose using CLAS as an existing framework when implementing pilot programs with the goal of identifying areas that need to be further defined and updated. The ultimate objective of standardized national medical Spanish education is to increase patient–physician language concordance to improve access and quality of care for Spanish-speaking U.S. patients on a population health level.25–27 As such, medical education research on medical Spanish skills should be linked with long-term outcomes for both learners and patients. Relatedly, medical research should develop strategies to intentionally and safely include non-English speakers as research subjects rather than excluding such populations because of the added challenges of informed consent.28 Such complex research requires national networks, assessment tool testing in an interinstitutional fashion, and funding support. Therefore, medical Spanish educational research should be linked to and supported by agencies that are dedicated to improving population health for vulnerable populations, reducing health disparities resulting from social risk factors, and developing long-term data collection practices.
Consensus recommendation 2 was developed by the program evaluation working group and confirmed by consensus. Figure 2 depicts the potential roles and partner organizations of a proposed multidisciplinary collaborative network for the Medical Spanish Taskforce.
Consensus recommendation 3: The panel provides a consensus list of core medical Spanish learner competencies to standardize the learning objectives and student performance expectations, targeting learners with intermediate Spanish proficiency
Medical Spanish courses should be directed toward students with some prior Spanish knowledge.5,29 After comparing multiple existing proficiency assessment methods, the expert panel consensus recommends using the validated self-assessment tool of the Interagency Language Roundtable (ILR)30 modified scale for physicians31 as part of precourse evaluations to characterize the starting proficiency levels of medical Spanish students and to require a minimum self-rating of fair as a prerequisite. The ILR scale has been shown to be comparable in accuracy to a validated oral proficiency interview for the lower and higher ends of the scale, though it is less accurate in the intermediate range.31 It is important to emphasize that the recommendation is to use the ILR as a precourse screening mechanism—not as a postcourse competency examination or certification. A rating of fair approximately corresponds to the low to mid-intermediate level in the American Council on the Teaching of Foreign Languages proficiency guidelines,32 which, though more comprehensive in evaluating functional general language proficiency, are not as rapid for self-assessment and do not have direct applicability to medical settings. As opposed to courses that target more rigorous written and academic proficiency, in a clinically focused course, the priority is having the language fluency and health-relevant cultural knowledge to enable direct patient–physician verbal communication. This is an objective that experts agree can be achieved with students at varying proficiency levels, including fair or above, although it may require personalizing the learner’s study plan, target areas, and timeline depending on that individual’s starting proficiency, strengths, and weaknesses. Within the acceptable proficiency range, students who enroll in a medical Spanish course at a lower proficiency level may be expected to require additional study to achieve all competencies than those who start at higher proficiency, though this has not been studied.
After a literature review of existing medical Spanish programs, expert panel discussion, and application of the AAMC existing framework for competency development,33 a consensus emerged on learner competency recommendations (Chart 1). Although the focus of the medical Spanish competencies is verbal communication, it should be noted that cultural elements are incorporated as critical components of patient–physician communication and should be included in medical Spanish courses. Cultural elements should include culturally acceptable health beliefs or practices, patient expectations and comfort regarding provider and family roles in health care, nonverbal cues and interpersonal skills that can affect communication (e.g., politeness norms), and the recognition of the heterogeneity of Latino cultural beliefs among individual patients to avoid inappropriate stereotyping. Recognition of the effect of socioeconomic status and public policy on access to care for the Latino community should also be considered as part of the social context of health addressed during medical Spanish courses. For example, patient cases used in medical Spanish courses (e.g., class presentations, simulated encounters, role plays) should reflect relevant, realistic sociocultural context pertaining to the target community (e.g., issues related to immigration, deportation, financial hardship, transportation, fresh food access) so that learners may recognize and learn to address the multitude of challenges to health care access that non-English-speaking patients may encounter in addition to language discordance.
Moreover, specific training on working with certified interpreters34,35 should be addressed as a corollary part of a linguistic curriculum both within medical Spanish courses and longitudinally throughout medical education, with the goal of teaching medical students to work with, not as, interpreters. Although competent use of medical Spanish would obviate the need for medical interpreting, it is essential to acknowledge that medical language competence may be gradually acquired and may vary from individual to individual; thus, providers must be empowered to self-assess their limitations on an ongoing basis to ensure patient safety and to learn to work with professional interpreters when necessary.
Consensus recommendation 3 was drafted by the competencies working group and confirmed by consensus.
Consensus recommendation 4: The panel provides a consensus core curriculum as a recommended structure for medical Spanish courses in U.S. medical schools
Proposed standard medical Spanish course curricula should be flexible enough to allow course integration at different points in the medical student cycle, depending on the curricular nuances of individual medical schools,36 and should be acknowledged institutionally via course credits for completion.5 Based on data from published courses29,37–41 as well as expert panel discussion, the panel has generated a consensus curricular structure for medical Spanish courses, which is summarized in Table 1.
The medical Spanish course syllabus can be organized according to 1 of the following 3 patterns:
- An organ system–based syllabus is recommended for medical students who have had prior clinical experiences and already have some knowledge of interviewing skills. This method may also be suited to teaching in conjunction with preclinical coursework that is organ system based if the course can correspond temporally with the material being covered in English. Suggested topics for lectures include cardiovascular, endocrine, gastrointestinal, genitourinary, hematologic/oncologic, musculoskeletal, neurologic, otolaryngologic/ophthalmologic, pediatric, psychiatric, and pulmonary systems.
- An interview-based syllabus is recommended for preclinical medical students who have little to no experience with general medical interviewing skills. This type of syllabus can be scheduled to correspond longitudinally with medical school coursework. Suggested topics for lectures include chief complaint/history of present illness, past medical and surgical histories, review of systems, family history, social/sexual histories, psychiatric history and mental status examination, physical examination, assessment/diagnosis, management/treatment plan, and procedures/consent.
- A problem-based syllabus is recommended for courses with an interdisciplinary audience (i.e., an audience that is not exclusively made up of medical students) because the material can be tailored to the medical content needed for each profession. Suggested topics for lectures include introduction to the general medical setting, pain relief and history of illness, diet and nutrition, fitness and physical therapy, breathing and circulatory issues, emergency evaluations (e.g., stroke, acute coronary syndrome, trauma, sepsis), social and sexual health, mental and behavioral health, family life and history, medication management, and hospital medicine.
Regardless of the syllabus selected, self-study assignments—such as written or audio- or video-recorded case reports, dialogues, patient medication or discharge instructions, student assignments on cultural topics, and simulated encounters—can be tailored to allow feedback from faculty. Course time and instructor feedback should incorporate role-play opportunities; effective communication skills; appropriate usage of terminology that can be understood by patients; grammar improvements if they affect communication; culturally appropriate health explanations; and special attention to challenging but common circumstances where increased need for professional interpreting should be considered, such as procedural consent, decision-making capacity, and delivering bad news. The curriculum structure (e.g., an intensive course, a global health immersion course, a longitudinal course spread over multiple months) may vary by institution. Additional study is needed to evaluate effectiveness of varied applications of medical Spanish curricula in medical schools.
As next steps in facilitating the creation and sustainability of high-quality medical Spanish courses, the expert panel proposes updating existing reviews of resources for medical Spanish education to identify recommended print and/or online educational materials for courses42 as well as to standardize training for medical Spanish instructors. Providing a train-the-trainer experience as a professional development tool could increase the pool of candidates who are able to teach medical Spanish courses. Specific tracks in the train-the-trainer experience should address areas in which specific educators would need more training (e.g., a physician educator may need to dedicate more time to proficiency assessment training, whereas an educator with an interpreter background may need more training in teaching and medical components). University language departments, hospital interpreter services, or community health worker programs may represent pools of educators who can be trained to teach medical Spanish courses, particularly in partnership with clinician educators, such as physicians.
Consensus recommendation 4 was presented by the curriculum and resources working group and confirmed by consensus.
Consensus recommendation 5: The panel recommends assessment of medical Spanish learner skills through SP encounters that incorporate interactive communication and interpersonal skills and proposes development of a national certification exam
Provider certification in medical Spanish is needed to deliver accountability and quality assurance for physicians wishing to use bilingual skills in clinical practice. A prior call to action has urged for the consideration of an examination similar to the United States Medical Licensing Examination Step 2 Clinical Skills exam that would be given in Spanish for U.S. physicians who wish to use Spanish skills in patient care.11
Although some individual schools include SP examinations in Spanish as part of medical Spanish courses, the process for case development and approval varies by institution and is often solely determined by the course instructor. There are also significant challenges in identifying, recruiting, and training SPs who are native Spanish speakers, although opportunities exist for community partnerships that can assist medical schools with this. Use of clinical performance centers and SPs also carries a cost that needs to be factored into medical school budgets but is already routinely included as part of standard English medical skills evaluations for medical students. The medical education literature has long established the utility of SP examinations in providing realistic settings in which to practice high-stakes skills in a safe environment.43 The expert panelists agree that while other assessments such as written, phone, or oral examinations may address components of medical Spanish skills, the type of examination that best addresses a comprehensive assessment of the physician’s ability to use medical Spanish in patient settings, including the evaluation of interpersonal and communication skills, would be an SP examination.
The assessment should be tailored to address the domains of general oral Spanish proficiency (e.g., fluency, pronunciation, grammar), listening comprehension (e.g., ability to understand the patient), oral medical Spanish proficiency (e.g., content-specific vocabulary, ability to explain medical concepts in patient-centered language), and communication and interpersonal skills (e.g., building rapport, verbal and nonverbal culturally appropriate communication skills) and should be directly linked to the course’s target core competencies (Chart 1). Further, the medical Spanish cases used for these examinations should not simply be translations of existing English SP cases but rather cases that reflect the appropriate sociocultural context of U.S. Spanish-speaking patients and so reflect the literacy levels, language use, and cultural norms that these patients may have. Given the diversity of nationalities, cultural beliefs, and social contexts of Latinos, a single case or encounter is unlikely to appropriately assess a provider’s competence. A series of virtual SP encounters or scenarios is a potential future strategy that would assess patient–physician communication skills while reducing barriers, such as cost or lack of native-speaking SPs, imposed by in-person clinical skills testing.
The Medical Spanish Taskforce should establish a shared repository of simulation-based cases and examination strategies and engage with organizations with prior experience in testing physician communication skills, such as the National Board of Medical Examiners (NBME). Further research and development are needed for a sustainable, validated, and reliable standardized certification process, including recertification guidelines and continuing medical education opportunities as well as incorporation and credentialing for providers who are currently practicing as bilingual physicians.
A certification process for practicing medicine in Spanish has the potential to be perceived as a burden or obstacle to caring for Spanish-speaking patients. The certification process should aim to empower and validate physicians’ bilingual skills and to protect vulnerable patients from well-meaning physicians who use limited skills to “get by,” while avoiding inappropriately overburdening physicians intending to care for underserved patients. For this reason, partnerships between medical institutions and certification authorities are expected to play a critical role in increasing accessibility of medical Spanish educational and assessment opportunities for physicians and students. For example, institutions may choose to cover costs for students or clinicians who want to take a medical Spanish course and/or certification examination.
Consensus recommendation 5 was proposed by the provider assessment and certification working group and confirmed by consensus.
Consensus recommendation 6: The panel recommends development of standardized evaluation and data collection processes for medical Spanish programs
While some courses are individually collecting data and show student satisfaction through comfort and knowledge self-assessments and qualitative data,29,37 implementation of a standardized curriculum should be coupled with a uniform process of data collection to evaluate the progress, impact, and quality improvement of national course development. Specifically, pre- and postcourse data should be collected, including learner proficiency assessments and evaluation of course components. Program and learner evaluations should include questions about unintended consequences of second-language acquisition, such as erroneous usage of language stemming from insufficient recognition of self-limitations. Standardizing the evaluation tools used across institutions would enable the merging of data for multi-institution analyses and for evaluation of course effectiveness across diverse settings.
Available data demonstrate that multiple elements of medical care are improved with patient–physician language concordance.44 It follows that medical education efforts to improve physician language skills and achieve patient–physician language concordance for Spanish-speaking patients may improve clinical outcomes and quality of care. Therefore, a research plan and data collection process that can evaluate long-term outcomes of learners and potentially link these to clinical outcomes for their Spanish-speaking patients should be considered. Organizations that already collect trainee and physician performance and skill data, such as the AAMC, NBME, Accreditation Council for Graduate Medical Education, and American Medical Association, would be impactful partners in effectively collecting physician language data across institutions.
Consensus recommendation 6 was developed by the program evaluation working group and confirmed by consensus.
Next Steps and Conclusions
The Medical Spanish Summit convened a group of experts in U.S. medical Spanish education and created a list of critical recommendations for future work, recognizing the emerging field as one that requires multidisciplinary attention. The expert panelists will be the initial invited members of the proposed Medical Spanish Taskforce and will continue to apply the working group structure that was implemented at the summit (Figure 1). The goals of the working groups will be to develop and finalize the educational elements of a standardized pilot program to be implemented and evaluated at a nationally representative sample of U.S. medical schools. Pending research to be conducted includes a systematic review of materials available for medical Spanish education, a survey on the current status of medical Spanish courses in U.S. medical schools, and the development of an assessment examination that, if validated, can be used as a certification method for medical students and providers. We will seek to develop a consortium that includes a nationally representative sample of U.S. medical schools that will comply with the consensus curricular guidelines, learner competencies, and assessment methodology so we can compare methods of implementation, evaluate their effectiveness, and improve the quality and precision of future recommendations.
We propose the establishment of partnerships with key stakeholders from the government, academic institutions, business, and the community (Figure 2) who can help link to existing work, provide interdisciplinary perspectives in the working groups, and secure funding. For example, federal agencies that establish standards of care with regard to language assistance22,24 and medical education organizations that establish competencies for undergraduate and graduate medical education programs have existing policies pertaining to communication skills, cultural competence, and health disparities45,46 that are well aligned with increasing access to and research on medical Spanish education and assessment. Such collaborations can be the catalyst needed to launch much-needed medical education research to establish best practices for medical Spanish course design and learner assessment. Future work should include an additional dimension of patient outcomes research to evaluate the connections between medical Spanish education, patient–physician language concordance, and clinical outcomes. If successful, this process could lead to replication in other health care fields, including nursing, pharmacy, dentistry, and physical and occupational therapy training programs as well as replication for other languages and cultural groups with the goal of ensuring quality health care for all.
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