When language becomes the barrier: IMGs and autism diagnoses

I once left grand rounds with a donut and a fake pager buzz because I couldn’t understand the speaker, who often was a natural Mandarin or Arabic speaker. Humor aside, this was not just my problem; it was a systemic failure.

I have spent decades in developmental-behavioral pediatrics, and one truth has never changed: Communication is the currency of medicine. Without it, trust collapses.

International medical graduates (IMGs) are vital to our workforce. They fill gaps in pediatrics, primary care, and subspecialties. But the uneven standards for English proficiency across medical schools create consequences that ripple far beyond admissions.

The uneven landscape of language standards

Harvard Medical School requires near-native fluency. TOEFL iBT, IELTS Academic, Duolingo, or TOEFL Essentials scores are mandatory unless the applicant has at least one year of full-time professional experience in the U.S. where English is the primary language.

Johns Hopkins University School of Medicine sets clear numeric cutoffs: TOEFL iBT 100, computer-based 250, paper-based 600.

Stanford University School of Medicine demands the highest bar: TOEFL ≥109 or IELTS ≥8.0, with placement testing if scores fall below.

By contrast, state schools lower thresholds to expand physician supply in underserved regions:

University of Nebraska Medical Center (UNMC): Accepts TOEFL iBT 80, IELTS 6.5, or Duolingo 120.
University of Arkansas for Medical Sciences (UAMS): Accepts Duolingo ~110, TOEFL iBT ~79, IELTS ~6.0.
University of Alabama (UAB): Requires TOEFL iBT 79, IELTS 6.0, or Duolingo 105.
University of Mississippi Medical Center (UMMC): Sets TOEFL iBT 80 or IELTS 6.5.

And then there is Texas. The Texas Medical Board requires functional fluency, enforced through Educational Commission for Foreign Medical Graduates (ECFMG) certification and jurisprudence exams, but publishes no neat cutoff. Texas is considered one of the toughest licenses to obtain overall.

Acronym key

TOEFL iBT: Test of English as a Foreign Language, Internet-Based Test
IELTS: International English Language Testing System
Duolingo: Duolingo English Test (computer-based proficiency exam)
ECFMG: Educational Commission for Foreign Medical Graduates

The spread is striking. Harvard, Hopkins, and Stanford demand mastery. Stanford wins over Harvard and Hopkins in language, and in football. Standards matter, whether you’re measuring TOEFL scores or touchdowns. I was already a high-priced free agent. Like the athletes who enter the transfer portal, I left Minnesota for Yale. Medicine doesn’t have name, image, and likeness (NIL) contracts, but the metaphor fits: You go where your education is enhanced, your voice will be heard, where your legacy can be amplified.

College athletes now earn millions through NIL. Where is NIL in pediatrics?

Nebraska and Mississippi set mid-range standards. Arkansas and Alabama accept lower scores, effectively saying: “At least we are not Alabama or Mississippi.” The irony is that these lowered thresholds allow more doctors into impoverished areas, even if they cannot speak the King’s English (other than George VI).

The clinical consequence

Now imagine a parent receiving a diagnosis of autism spectrum disorder (ASD) from a physician whose English is halting or heavily accented. The child may already struggle with expressive language. The parent is overwhelmed. The physician is trying to explain complex criteria and interventions. Both sides are lost in translation.

We eliminated literacy tests for voting because they were discriminatory. Yet in medicine, we tolerate uneven standards for language proficiency. The result is not disenfranchisement, but disorientation, families left outside the circle of clarity.

In my own practice, I calibrated language by audience. Referral sources received reports at a 10th grade level. Parents were given explanations closer to 8th grade. In the Army and Air Force, I adjusted further: Officers received 8th grade explanations, enlisted 4th grade. This was not condescension; it was survival. Communication must meet the audience where they are, or it fails.

If we expect families to trust us with their children, we must demand clarity from ourselves. That means setting consistent, rigorous language standards for IMGs, supporting them with training, and recognizing that fluency is not a luxury; it is a clinical competency.

It’s almost comic. In the 1960s, ads claimed 9 out of 10 doctors recommended Lucky Strike cigarettes. Ronald Reagan himself pitched Chesterfields. Today, we tolerate uneven language standards for IMGs, a different kind of absurdity, but just as dangerous.

Medicine cannot afford to dither on language. Patients deserve clarity. Families deserve understanding. And children deserve care explained in words their parents can grasp.

History will judge us not by our innovations, but by whether families could understand them.

Ronald L. Lindsay is a developmental-behavioral pediatrician.