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

BMC Medical Education volume 25, Article number: 701 (2025) Cite this article

Abstract

Background

Language barriers in medical education, particularly in countries where foreign languages are used as the medium of instruction, pose significant challenges for domestic medical students. These barriers hinder academic performance, comprehension, and communication with patients, ultimately impacting the quality of healthcare delivery. Despite the prevalence of this issue, a comprehensive understanding of its effects remains underexplored. This systematic review aims to synthesize evidence on language barriers in medical education and propose strategies to address them.

Methods

Following PRISMA guidelines, we conducted a systematic review of studies published up to March 21, 2024, using PubMed, Scopus, and Web of Science. Eligible studies focused on language barriers faced by medical, pharmacy, nursing, dental, or veterinary students in countries relying on foreign-language-based medical education. Data extraction included study characteristics, reported language barriers, and their impact on education and patient communication. Quality assessment was performed using the Mixed Methods Appraisal Tool.

Results

From 5,410 citations, 49 studies involving over 14,500 students met the inclusion criteria. Most studies (n = 32) were conducted in Arab countries, with 15 in Saudi Arabia. Two key themes emerged: (1) Education and Academic Performance: Students frequently reported difficulties comprehending foreign-language textbooks, lectures, and assessments, leading to poor academic outcomes, increased stress, and higher dropout rates. (2) Communication Skills with Patients: Studying and training in a foreign language hindered students’ ability to communicate effectively with patients in their native language, impacting empathy, medical history collection, and overall patient care. Many studies highlighted students felt more confident and effective when using their native language during clinical interactions.

Conclusion

Language barriers in foreign-language-based medical education significantly impede students’ academic performance and patient communication skills. Addressing these challenges through reforms, such as integrating native language instruction and supplemental language training, is crucial to enhancing medical education quality and ensuring effective healthcare delivery. Future research should explore innovative solutions, including bilingual education and AI-driven translation tools, to bridge these gaps.

Peer Review reports

Introduction

Medicine is a cornerstone of public health and individual well-being. Quality medical education plays a pivotal role in shaping competent healthcare professionals who are not only technically skilled but also empathetic and patient-centered [1, 2]. By equipping future doctors, nurses, and other healthcare providers with essential knowledge and skills, medical education lays the foundation for effective diagnostics, treatment, and patient care. Thus, ensuring that medical education is both effective and accessible is critical to strengthening healthcare systems globally [2].

Language is a key factor in the effectiveness of medical education. As the primary medium of instruction, language shapes how medical knowledge is conveyed—whether through textbooks, lectures, or clinical interactions with patients [3, 4]. It is a vital learning tool that facilitates comprehension, academic performance, and professional communication. Therefore, the choice of language in medical education profoundly influences the quality of learning outcomes and the preparedness of healthcare providers [3].

A global screening of instructional languages in medical education revealed that 105 countries use their native languages as the primary medium of instruction. Conversely, 74 countries—primarily in developing regions, including Africa and the Arab world—rely on foreign languages for medical education (Fig. 1) [5]. This reliance often stems from historical legacies, such as colonialism, which imposed foreign languages on educational systems [5, 6]. While adopting a foreign language (mostly English) can offer access to extensive global medical knowledge, it may also create significant challenges for domestic students [3, 7,8,9]. Research highlights that education in a native language fosters better comprehension, academic performance, and communication, all of which are critical for effective patient care [3].

Fig. 1
figure 1

The status of reliance on native languages in medical education worldwide. (Adapted from Hamad A.A., 2023; doi: https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.glmedi.2023.100007)

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Reliance on a foreign language in medical education introduces numerous barriers. Students may struggle to grasp complex medical concepts, leading to gaps in understanding and lower academic performance [7, 10]. Furthermore, their ability to communicate effectively with patients in their native language may be hindered, impacting the quality of care [11]. This language barrier not only affects learning but also disrupts the critical connection between medical professionals and their patients.

Given these challenges, it is essential to examine the impact of using foreign languages in medical education on students’ learning experiences, communication skills, and, ultimately, the quality of healthcare delivery. This study aims to systematically review the challenges faced by domestic medical students in countries that adopt a foreign language as the primary medium of instruction in medical education.

Methods

Search strategy

This systematic review adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [12]. A comprehensive search was conducted across PubMed, Scopus, and Web of Science databases up to March 21, 2024. The search terms included: (“medical education” OR “medical students” OR “nursing students” OR “pharmacy students” OR “dental students” OR “dentistry students” OR “veterinary students”) AND (language or linguistic) AND (barriers OR difficulties OR challenges OR obstacles OR problems OR issues OR struggles OR dilemmas OR limitations). No filters or language restrictions were applied. Additionally, the references of the included studies were screened to ensure comprehensive coverage.

Inclusion criteria

This review aimed to summarize language barriers encountered by medical students studying in countries where foreign languages are integral to medical education. The inclusion criteria were as follows: (a) primary studies involving medical, pharmacy, dental, veterinary, or nursing students; (b) studies conducted in countries relying on foreign languages in medical education [5]; and (c) studies reporting language barriers experienced by students in various educational aspects (e.g., comprehension, patient communication). Exclusion criteria included studies focusing on: (a) language barriers faced by international students studying abroad; (b) language barriers affecting specific minority groups within a country; (c) faculty or healthcare professionals without student involvement; (d) language barriers experienced by patients. Reviews, editorials, and abstracts were also excluded.

Outcomes of interest

This review concentrated on two primary outcomes. Firstly, it examined language barriers encountered by students within the educational context, encompassing comprehension of concepts, study time, information retention, and participation in discussions. Secondly, the review explored language barriers during student-patient communication in training or Objective Structured Clinical Examinations (OSCEs) exams. Specifically, it aimed to analyze how students communicate with patients in their native language following education in a foreign language.

Screening, data extraction, and quality assessment

Two reviewers independently screened the titles and abstracts of the identified citations. Full texts of relevant articles were then reviewed by a third author for final inclusion decisions. Data extraction was carried out by two authors using an online form, covering study year and country, design and sample size, participants, objectives, main findings, and reported language barriers. Quality assessment was conducted by two reviewers utilizing the Mixed Methods Appraisal Tool to evaluate the various study designs (qualitative, quantitative, and mixed methods) [13]. Any discrepancies during screening, data extraction, or quality assessment were resolved through discussion with a third author.

Analysis

Qualitative synthesis followed the methodology for narrative reviews outlined in the Cochrane Handbook [14]. Language barriers were categorized into two themes: (1) Educational and Academic Performance Barriers and (2) Patient Communication Barriers. A summary table was created to systematically present extracted data, including study ID, country, study design, participants, sample size, proportion of male participants, study aims, key findings, and reported language barriers. This approach enabled structured comparison and exploration of findings across diverse contexts and study designs. Additionally, the quality of the included studies was analysed and summarized in a table following the criteria outlined above.

Results

Characteristics of the included studies

Our search yielded a total of 5,410 citations. After screening titles and abstracts, we identified 90 records for eligibility assessment. Among these, 22 studies focused on international students studying in foreign countries, four on medical professionals, six on patients, and nine on students from minority groups (Fig. 2). Ultimately, 49 studies involving over 14,500 students met the inclusion criteria and were included in our analysis [4, 7, 8, 10, 11, 15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59]. All studies were conducted in countries that utilize second-language-based medical education. The majority (n = 32) were carried out in Arab countries, with 15 studies conducted in Saudi Arabia. The studies comprised seven qualitative, six mixed-method, and the remainder quantitative research. Two studies were published in Arabic, while the others were in English. Participants primarily consisted of medical students, although some studies also included pharmacy, nursing, dental, and veterinary students. The overall quality of the studies was generally good, as detailed in the Supplementary file. Table 1 summarizes the characteristics, aims, and main findings of the included studies.

Table 1 Characteristics, main findings, and language barriers reported in the included studies
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Fig. 2
figure 2

The PRISMA flow diagram

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Barriers in education and academic performance

Numerous studies have highlighted significant barriers in education that adversely affect academic performance among medical and nursing students (Table 1). A recurrent theme is the challenge posed by language proficiency, particularly in English as the foreign language of instruction. For instance, studies indicated that students often struggle with understanding English-language textbooks and assessments, leading to decreased academic performance and increased dropout rates. In Saudi Arabia, approximately one-third of medical students reported difficulty comprehending English texts, with limited proficiency negatively influencing their exam results [10, 17]. Additionally, the use of foreign languages in teaching has been linked to feelings of inadequacy among students; many feel unprepared for clinical interactions due to insufficient language skills [19, 60]. This disconnect between the language of instruction and students’ native languages not only hampers their academic success but also exacerbates stress and anxiety related to performance evaluations [21, 34, 49].

For example, in Saudi Arabia, Almoallim et al. found that poor English proficiency was ranked as the second most significant difficulty faced by first-year medical students, with female students identifying it as their top challenge [19]. Similarly, Alqahtani reported that while Saudi nursing students had high academic achievement, their English language usage was low, particularly in speaking and writing, which significantly influenced their academic performance [21]. In Morocco, Abou Sahda et al. revealed that a third of medical students felt that French, the language of instruction, hindered their academic success, with 44% reporting increased learning time and 21% struggling to communicate with patients [61].

Moreover, a study in Sri Lanka found that English language proficiency was a significant predictor of academic performance among dental students, with weaker English skills correlating with lower GPAs [23]. In India, Amulya et al. reported that 88.5% of medical students could not comfortably communicate in the local language, leading to barriers in bedside teaching and learning [22]. These findings underscore the pressing need for educational reforms that accommodate native languages to enhance comprehension, participation, and success in medical education.

Barriers in communication skills with patients

Language barriers significantly impact medical students’ communication skills with patients, often resulting in suboptimal care and patient outcomes (Table 1). Many studies reveal that students trained primarily in a foreign language struggle to effectively convey empathy, understand patient concerns, and conduct thorough medical histories in their native language [11, 29]. For instance, students from the United Arab Emirates reported feeling more comfortable and confident communicating with patients when using their native language, highlighting the challenges posed by English as a language of instruction [28, 32]. Moreover, the lack of proficiency in English among students has led to difficulties in patient interactions, with many expressing a desire for additional training in their native language to enhance their communication abilities [25, 60].

In Qatar, Diab et al. found that pharmacy students felt more confident performing OSCEs in Arabic, their native language, compared to English [25]. They also believed that using Arabic in OSCEs could improve patient care. Similarly, Alnahdi et al. reported that only 33.8% of medical students in Saudi Arabia felt confident taking medical histories in Arabic after being trained in English, with 68% recommending the addition of short Arabic history-taking courses to improve their skills [60].

In the United Arab Emirates, Hashim et al. found that medical students trained in English struggled with complex communication tasks, such as expressing empathy and eliciting patients’ expectations, during patient interactions [29]. This was further supported by another study, that reported that only 28% of medical students felt confident taking a patient history in Arabic after learning communication skills in English [11]. Similarly, Jabali’s study in Palestine found that half of the medical students preferred Arabic over English as the language of instruction, with many expressing concerns that using English might hinder their ability to communicate with patients after graduation [33]. These findings highlight the critical need for integrating native language instruction into medical curricula to improve communication skills, ensure better patient care, and foster a more empathetic healthcare environment.

Discussion

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.

Conclusion

Language barriers in foreign-language-based medical education significantly impede students’ academic performance and patient communication skills. This systematic review highlights the cognitive and emotional challenges students face when learning in a non-native language, as well as the disconnect between classroom training and real-world clinical interactions. Addressing these challenges through targeted reforms is crucial to enhancing the quality of medical education and ensuring effective healthcare delivery. To bridge these gaps, we propose a bilingual education model that integrates native languages into core medical curricula while maintaining English proficiency training. This approach balances the benefits of global scientific engagement with the practical advantages of local language proficiency. Additionally, leveraging AI-driven translation tools can provide real-time support for students, reducing barriers to accessing foreign-language resources. Future research should explore the long-term outcomes of bilingual programs and the efficacy of AI tools in bridging language gaps. By addressing these barriers, institutions can enhance educational equity and prepare healthcare professionals to meet the linguistic and cultural needs of diverse populations.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

AI:

Artificial Intelligence

EMI:

English as a Medium of Instruction

GPA:

Grade Point Average

L1:

First Language (Native Language)

L2:

Second Language (Foreign Language)

MCQ:

Multiple Choice Question

MMAT:

Mixed Methods Appraisal Tool

OSCE:

Objective Structured Clinical Examination

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

TOEFL:

Test of English as a Foreign Language

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Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB).

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  1. Faculty of Medicine, Menoufia University, Menoufia, Egypt

    Abdullah Ashraf Hamad

  2. Faculty of Medicine, Alexandria University, Alexandria, Egypt

    Doaa B. Mustaffa & Bassant Amin

  3. Faculty of Medicine, Al-Azhar university, Gaza, Palestine

    Asmaa Zakria Alnajjar

  4. Faculty of Medicine, Mutah University, Al Karak, Jordan

    Raghad Amro & Ibraheem M. Alkhawaldeh

  5. Prince Hamza Hospital, Amman, Jordan

    Mohammad Ghassab Deameh

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  1. Abdullah Ashraf Hamad
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AAH contributed to conceptualization, designing the manuscript, searching the literature, writing the original draft, reviewing, creating results, administrating, and supervision. DBM and AZA contributed to screening, data extraction, quality assessment, and writing the original draft. RA, MGD, and BA contributed to screening, data extraction, quality assessment. IMA contributed to writing the original draft and reviewing. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.

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Hamad, A.A., Mustaffa, D.B., Alnajjar, A.Z. et al. Decolonizing medical education: a systematic review of educational language barriers in countries using foreign languages for instruction. BMC Med Educ 25, 701 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12909-025-07251-2

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BMC Medical Education

ISSN: 1472-6920

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